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Daily transcripts
Hearing summary
16h June 1999
Today the Inquiry heard from Mr Roger Baird, Medical Director of United Bristol
Healthcare NHS Trust (UBHT) from April 1997 to March 1999. He described his period as
Clinical Director for Surgery and gave his views of the pressures faced by the Cardiac
Surgical Service including the technical difficulty of the work undertaken within the
specialty and the lack of investment to develop the service. He outlined the lines of
accountability and responsibility within the Directorate and commented on his
relationships with the General Manager for Surgery and the Chief Executive. He described
the primary role of the Medical Director as being to lead on professional issues in the
group of Executive Directors, in Clinical Committees of the Board and at the Trust Board.
He identified another key responsibility as being to assist and support the Clinical
Directors in the management of consultant staff. Mr Baird described the Trust procedure
for handling complaints from the public and for dealing with concerns raised internally.
Mr Baird went on by answering questions about the funding for surgical services and in
particular cardiac surgical services. He then discussed the management of nursing staff
within the Trust. He concluded by discussing the process by which new surgical procedures
where introduced.
|
FULL TRANSCRIPT
1 Day 29, 16th June 1999
2 (1.00 pm)
3 THE CHAIRMAN: Good afternoon, ladies and gentlemen. Good
4 afternoon, Mr Langstaff.
5 MR LANGSTAFF: Good afternoon, sir. Today we have Mr Roger
6 Baird, who was, for a time, Clinical Director of Surgery
7 and was thereafter Medical or Clinical Director of the
8 Trust and who has been a surgeon at the Bristol Royal
9 Infirmary throughout the period with which we are
10 concerned. We are grateful to him for making himself
11 available today. The reason for the 1 o'clock start --
12 in fact 10 past 1 -- is that he was this morning
13 operating, so it is to accommodate that that we meet at
14 this time.
15 Mr Baird, before I ask you to take the oath, let
16 me indicate because of the timings, so that those who
17 have other concerns can note them, what we propose to do
18 is to go on for a period to about 2.15/2.20 and take
19 a break for 10 or 15 minutes then; proceed until
20 3.30/3.45 and have a further break until 4 o'clock.
21 Whatever happens, we propose to finish no later than
22 5 o'clock.
23 Mr Baird, you know, I think, that we stand to take
24 the oath?
25 MR ROGER NEALE BAIRD (SWORN):
0001
1 Examined by MR LANGSTAFF:
2 Q. Mr Baird, you are Roger Neale Baird?
3 A. That is correct.
4 Q. Can we have on the screen WIT 75/1? That is the first
5 page, is it, of a statement which you made to the
6 Inquiry?
7 A. Yes.
8 Q. Can we go to 75/20? That is your signature?
9 A. Yes.
10 Q. You adopt, do you, the contents of that statement as
11 true and accurate, and your evidence to this Inquiry?
12 A. Yes.
13 Q. You are by profession a vascular surgeon, so your work
14 has, as I understand it, not brought you directly into
15 contact with cardiac surgery as such?
16 A. Yes.
17 Q. You fulfilled a number of roles throughout your time,
18 about which you tell us at page 1 of your statement.
19 Shall we look at that? Those that you have selected for
20 us as most important are shadow Clinical Director for
21 Surgery from 1990 onwards and then becoming Clinical
22 Director, and you remained the Clinical Director for
23 Surgery until November 1993, when you became first of
24 all the Chairman-elect and then the Chairman of the
25 Hospital Medical Committee and that overlapped with
0002
1 a period of time during which you were acting Medical
2 Director and then Medical Director of the UBHT until
3 March 1999?
4 A. Yes.
5 Q. You continue as a vascular surgeon at the Trust and
6 Mr Steven Miller QC is present in the chamber as your
7 legal representative?
8 A. Yes.
9 Q. You were for a while prior to 1990 I think the
10 Divisional Vice Chair of the Division of Surgery?
11 A. Yes.
12 Q. To which you were elected on 13th November 1989 -- you
13 probably do not remember the date. You were at one time
14 chair of the King Edward surgeons?
15 A. Yes.
16 Q. Can you tell me, what are the King Edward surgeons?
17 A. The King Edward surgeons are the surgeons who work in
18 the King Edward building. The King Edward building is
19 a building that was built in 1912, I believe, and it
20 housed basically the general surgeons and the urology
21 surgeons.
22 Q. What I want to ask you about will come under a number of
23 headings, but first of all, if I can begin by asking you
24 essentially about the responsibilities which you had
25 when you were the Clinical Director of Surgery. That is
0003
1 what I wish to focus on.
2 Is it the case that you would agree that the
3 person with immediate responsibility for the clinical
4 care of a patient is the nurse or other clinician who is
5 most directly concerned with the treatment that patient
6 is currently getting?
7 A. Yes.
8 Q. Beyond the immediate clinician, who takes responsibility
9 for the clinical care of that patient? Who did? This
10 is in the time you were Clinical Director.
11 A. I think the clinical care of a patient has always been
12 perhaps facetiously described as "two consenting adults
13 in private". It is the patient and the doctor or the
14 patient and the nurse. I do not think, in terms of the
15 view that the patient has of a particular episode of
16 illness, that the patient sees anyone other than the
17 doctor and the nurse who looks after them.
18 I think the wider environment comes behind the
19 doctor or the nurse if one tries to set them in the
20 context of the way in which the facilities are provided
21 for the patient to be treated.
22 Q. Suppose that one had a nurse who treated a patient well
23 below the standard of care to be expected from the
24 nurse. The nurse, obviously, would himself or herself
25 have responsibility for the patient and for the absence
0004
1 of proper care, but above the nurse, there would be
2 someone else who would have responsibility, would there
3 not?
4 A. Of course.
5 Q. That would be who, the Ward Sister?
6 A. A more senior nurse, depending on the context in which
7 the nurse was working. Some nurses would be working in
8 the community as part of the hospital; some nurses would
9 be working in the outpatient clinics, some in the wards,
10 some in the operating theatres. So on the nursing side
11 there has always been a more hierarchical structure than
12 on the medical side.
13 Q. During the time you were Clinical Director for surgery,
14 in the case of an individual nurse above him or her,
15 that would be who? Who would take responsibility?
16 A. I would stand to be corrected, but a strong nursing
17 presence in the Directorate of Surgery when I was there
18 was Mary Luhman, a very good nurse, who is currently the
19 General Manager of the community, but at that time in
20 the early 1990s, she -- I think her office was one of
21 the assistant managers in the nursing directorate. She
22 is actually a nurse.
23 Q. To whom was she responsible or accountable to in her
24 responsibility for the care provided by the individual
25 nurses?
0005
1 A. In terms of her nursing accountability, she would be
2 accountable to Margaret Maisey, who is here in this
3 room. I am not sure, but I think it was a direct line
4 of accountability. I do not wish to misrepresent her,
5 but I think Margaret Maisey had two or three key nurses
6 in key areas of the hospital in each of a number of key
7 areas of the hospital who were her eyes and ears on the
8 nursing side.
9 Q. If it was a doctor who was the clinician rather than
10 a nurse, how would the line of responsibility for the
11 care go upwards?
12 A. It would depend if the doctor was in one of the training
13 grades or in a career grade. By a career grade, I mean
14 a consultant, largely. For doctors in the training
15 grade, most -- pretty well all trainees had some kind of
16 training supervisor within the hospital, depending on
17 the specialty in which the doctor worked. Then, and
18 now, people about whom there are concerns on the
19 training side are usually looked after by a fairly
20 well-established training supervisory network which has
21 various links, one to the regional postgraduate medical
22 dean, and then also, within specialties, for example, in
23 my own specialty, trainees in general surgery would have
24 a surgical training co-ordinator who would be one of the
25 consultant surgeons. If a question arose about a Senior
0006
1 House Officer or a Registrar, then the training
2 supervisor would deal with that. On the other hand, if
3 on the other hand the trainee was a pre-registration
4 house officer, then the University would keep an eye on
5 that person because that was a shared responsibility
6 between the University and the hospital.
7 On the consultant side on the other hand, that
8 kind of accountability really rested with those holding
9 representative office amongst the consultants, by which
10 I mean the Clinical Directors, the Associate Clinical
11 Directors and the Medical Director.
12 Q. So you, for your part, when you were Clinical Director
13 of Surgery, had responsibility for the clinical
14 performance or lack of it of the individual consultant
15 surgeons in the Directorate of Surgery?
16 A. Yes.
17 Q. Your responsibility, in respect of that: to whom were
18 you accountable?
19 A. I would see myself accountable to the Medical Director
20 and the Chief Executive.
21 Q. So the Medical Director, as you would have seen it, had
22 a direct line responsibility for the clinical care at
23 the bedside of the individual consultant?
24 A. I would see it as a responsibility at one step removed.
25 Let me explain this, because having been the Medical
0007
1 Director, and there being about 14 clinical directorates
2 in a very large Trust, I never felt that I had a direct
3 link to any of one of our 200 consultants, and I would
4 be available to advise and assist the Clinical Director
5 who would be my eyes and ears there.
6 Q. So although you may not have had a direct line in the
7 sense of talking to the consultant concerned because the
8 Clinical Director was your eyes and ears and no doubt to
9 an extent your mouthpiece --
10 A. Of course.
11 Q. -- you would nonetheless accept that when you were
12 Clinical Director/Medical Director you had
13 a responsibility for the Clinical Director's discharge
14 of his responsibility for the consultant's discharge of
15 his or her responsibility for the individual patient?
16 A. Yes.
17 Q. Can I ask you to go to page 19 of your statement?
18 During the 1980s you did not have the directorate
19 responsibilities which you were to assume in 1990?
20 A. Yes.
21 Q. Nor did you have the divisional responsibilities which
22 you assumed in 1989?
23 A. Yes.
24 Q. Nonetheless, may I ask you about what you say here? You
25 say, in the first sentence:
0008
1 "In the 1980s, the cardiac surgical service
2 performed reasonably in difficult circumstances."
3 Those words, "in difficult circumstances" are
4 pregnant with meaning. What were the difficult
5 circumstances?
6 A. Could I take you to the third sentence, which reads:
7 "The challenges that they faced with technically
8 difficult work was viewed sympathetically by the
9 hospital community."
10 As a vascular surgeon, I operate on arteries other
11 than the heart, and I know how technically difficult it
12 is. So I know better than most how technically
13 difficult cardiac surgery is. That is the sense of what
14 I wished to convey by that.
15 Q. So the "difficult circumstances" you refer to in the
16 first sentence are no more than the technical
17 difficulties of doing the operation?
18 A. Yes. In the 1980s, in my own specialty, there were
19 technical advances going on that we were keeping pace
20 with and we were hopefully ahead of most. We faced
21 technical challenges almost every year because the
22 others elsewhere would produce better ways of doing
23 things and we might produce better ways of doing things
24 and we would modify and adapt and develop the way we
25 treated our patients in order to improve our results.
0009
1 I suspect -- well, I know that that was happening
2 in cardiac as well, but cardiac is not easy.
3 Q. I am sure no-one suggests that it is. The words "in
4 difficult circumstances" might convey to the average
5 reader that a comparison has been made here with
6 circumstances elsewhere, that difficult circumstances
7 might normally, perhaps, be taken to refer to
8 circumstances where the operating theatre is antiquated
9 or the staffing is low or there is an absence of
10 expertise or -- lots of factors which may affect what
11 would otherwise be the ordinary exercise of great skill.
12 You did not intend it in that way?
13 A. I do not think there is very much ordinary about cardiac
14 surgery.
15 Q. The words I used were "the ordinary exercise of great
16 skill".
17 A. Yes. I have a great respect for cardiac surgery and
18 I watch it going on around the country and abroad. In
19 the South West we had one unit. The evidence from
20 Mr Nix shows the number of cases in the 1980s that were
21 being done. In the South West we were at the bottom of
22 the national league table for numbers of cardiac
23 surgical cases done.
24 One of the reasons for that, it seemed to us, was
25 a lack of investment in the service, so there is an
0010
1 element there of difficult circumstances. We felt in
2 certain Metropolitan areas they were close to the areas
3 where the decisions were being taken, they could ring up
4 and beg for more money from the centre and we felt that
5 we were a little remote and perhaps we did not fare so
6 well in consequence.
7 Q. So your perspective, leave aside for a moment whether it
8 was right or wrong, but your perspective was, as country
9 boys, you did not get the benefits which the metropolis
10 had and those were benefits in terms of funding?
11 A. The one fact I would hang that on, and I can remember an
12 article in the BMJ about it, was the number of heart
13 bypass cases done per year by region and the South
14 Western region was the lowest. I cannot remember the
15 date, but I can remember being very struck by that in
16 the early 1980s. I felt sorry for them, because I felt
17 they should have had a better deal.
18 Q. So the "difficult circumstances" refers not only to the
19 technical difficulty of the operation, but also to the
20 impact of underfunding?
21 A. Yes.
22 Q. The underfunding had its consequences, as you saw it;
23 and again, I appreciate it may only be a matter of
24 perspective, but as you saw it in what respect? What
25 concrete result was there from the underfunding?
0011
1 A. If you have funds, you can build buildings, you can
2 create facilities and you can employ staff. The degree
3 to which you do that is a matter of degree. Doctors
4 have always done the best they could for their patients
5 with what was available. They were doing the best with
6 what was available. If they had more, they could have
7 done more.
8 Q. So your perspective was that there were shortages in
9 staffing, buildings and equipment?
10 A. Yes.
11 Q. You say that the cardiac surgical service performed
12 "reasonably", in those circumstances, where there were
13 these shortages of buildings, equipment and staff and
14 the technical difficulties to which you have referred.
15 "Reasonably" again is a word which conveys
16 a number of different messages, depending on who is
17 looking at what is reasonable.
18 It is not a word here, am I right, which is
19 intended to praise the quality of the service
20 comparative to service elsewhere?
21 A. I would say it put it in the middle.
22 Q. How did you know?
23 A. Well, almost by exclusion. I think one becomes aware of
24 the so-called "Blue Ribbon" services, and you are aware
25 of the lame ducks. I did not see cardiac in either of
0012
1 these categories, so it must have been in the middle.
2 Q. That is looking at it internally, comparing within the
3 services of the hospital?
4 A. Certainly that, and also, the feel that I had from
5 a surgical point of view of how other cardiac surgical
6 departments were perceived as performing, as one has
7 a feel for these things by the people one talks to in
8 the surgical community.
9 Q. So it is the grapevine, the word of mouth that goes
10 round?
11 A. Yes.
12 Q. When did you first become a consultant?
13 A. In 1977.
14 Q. So you were an established consultant in the 1980s?
15 A. Yes.
16 Q. So you would get around and see colleagues in your own
17 specialty elsewhere?
18 A. Yes.
19 Q. And you would learn, would you, in the course of doing
20 that, something of the reputation which various
21 departments held in various parts of the country?
22 A. Yes, and at meetings one went to one would meet
23 colleagues from other places.
24 Q. That is really a process of reputation and coffee room
25 chatter, and so on?
0013
1 A. All of that, yes.
2 Q. You say in the next sentence, in paragraph 67, that the
3 cardiac surgeons, Messrs Wisheart and Keen, and later
4 Messrs Hutter and Dhasmana, "were seen as hard-working
5 competent and conscientious"?
6 A. Yes.
7 Q. Who was doing the "seeing"?
8 A. Well, may I say, for one I was, and I believe that
9 others perceived them similarly. We are a large Trust
10 and I cannot speak for everyone, but I do not think my
11 feeling about them was out of synch' with what the
12 majority in the Trust were feeling.
13 Q. It could not be a silent majority because you picked it
14 up from the coffee room chatter we have been describing?
15 A. Yes.
16 Q. So the view you are putting forward is the collective
17 view gleaned from those sources, is it?
18 A. I would think so, yes.
19 Q. When you say "seen as", that was the general reputation
20 amongst their fellow colleagues?
21 A. Yes, well, everyone has a perspective from which they
22 view these things and mine is a surgical perspective.
23 I do not think I would claim this is the view of
24 everyone who worked in the Trust.
25 Q. So what you are saying is that some within the Trust
0014
1 during the time at which you are speaking -- the
2 1980s -- would not have seen one or other of the
3 individuals you name, leave aside the names for
4 a moment, as hard-working, competent and conscientious?
5 A. Yes. I am sure there are people who would not agree
6 with that judgment.
7 Q. And those people existed during the 1980s?
8 A. Yes. I think one of the features about cardiac surgery
9 is that the intervention and the outcome are so closely
10 related to each other that they are quite easily linked
11 in people's minds.
12 I think if you take another example, let us say
13 you take something simple, like the repair of a hernia,
14 somebody may be good at it and have a low recurrence
15 rate and somebody may be bad at it and have a high
16 recurrence rate, but the recurrences come so long after
17 the intervention it is difficult for the patient and
18 anybody else to link the intervention with the outcome.
19 So the standards by which cardiac were and are
20 judged are not the same as the standards by which others
21 are judged.
22 Q. What you are saying is that in the case of the surgeon
23 doing a hernia repair, the colleagues will have probably
24 no basis other than watching the operative technique of
25 those that do and chatting to the individual concerned
0015
1 and forming a view of him or her, as to how well they
2 performed their surgery, because you do not get
3 immediate feedback?
4 A. Quite.
5 Q. Whereas with cardiac surgery, the patient sadly dies, or
6 after the surgery is plainly disabled by part of it, for
7 whatever reason, that is immediately apparent and people
8 take that on board?
9 A. Exactly.
10 Q. In that way, one may detect differences between
11 individual surgeons, and reputations develop
12 accordingly?
13 A. I believe that, yes.
14 Q. So what you are saying to me is, is it, that whereas
15 most people within the hospital in the 1980s saw
16 Messrs Wisheart, Keen, Hutter and Dhasmana on the basis
17 that you have described, as hard-working, competent and
18 conscientious surgeons, there were those who did not do
19 so, and on either side of the view, the view will be
20 based upon a perception of the consequence of the
21 interventions which those surgeons have been engaged in?
22 A. Yes.
23 Q. The next sentence which you have in paragraph 67, the
24 challenges, you say, that the surgeons faced with
25 technically difficult work "were viewed sympathetically
0016
1 by", you use this phrase, "the hospital community."
2 How does that differ from the people doing the
3 "seeing" in the previous sentence?
4 A. I suspect they are the same people. After all, if you
5 want to find out if a surgeon is any good, you usually
6 ask the theatre sister. You cannot ask the surgeon or
7 their colleagues, but the theatre sister watches
8 everyone operate and she can sometimes give you quite
9 a good insight into the light and shade of one person's
10 technical performance against another.
11 Q. Skipping forward a little to the time when you were
12 Clinical Director for Surgery and you had your
13 responsibility to discharge, you would have a chat or
14 two with the theatre sister?
15 A. Very helpful, on occasions.
16 Q. And that might alert you to problems, if problems
17 existed?
18 A. Oh, yes.
19 Q. The way you are saying that, it obviously did, on some
20 occasions?
21 A. Of course.
22 Q. Again, jumping forward -- I will come back to the
23 paragraph we are at in a moment -- if you were alerted
24 to such problems by the theatre sister when you were
25 Clinical Director, you would do something about it?
0017
1 A. Yes. You use the word "problem", but sometimes you have
2 to use the word "allegations", and you have to say that
3 there is an accuser and somebody has had allegations
4 made against them, and these allegations are not always
5 well-founded and the person who makes the allegations
6 may not have the whole picture when they make the
7 allegations.
8 Q. I am taking you a little out of turn; it is because you
9 raised the question of the theatre sister and I wanted
10 to explore it for a moment.
11 Suppose the theatre sister, with whom you get on
12 well, has a word in your ear about Mr X as a surgeon.
13 A. Yes.
14 Q. And what she is telling you is that Mr X is particularly
15 slow, let us suppose, and is very grumpy and difficult
16 to deal with, which means he does not get the best out
17 of the staff around him, and there are one or two
18 incidents which have caused her concern in the operating
19 theatre, something along those lines.
20 You would not regard that as an allegation, as
21 such, against the surgeon, or would you? We are talking
22 about the time you were Clinical Director, so the early
23 1990s.
24 A. No, that would not be an allegation. That would be
25 "intelligence". It might be somebody else who made the
0018
1 allegation and I would go to the theatre sister and say,
2 "Tell me what is going on?" You get good information
3 from the experienced nurses.
4 Q. So the way you would chat with the theatre sister would
5 come about, would it be part of a general review you
6 were conducting, saying "Any problems, Fiona?" or
7 whoever it was?
8 A. No, the nature of these things is that one tends to be
9 reactive rather proactive. Maybe that is a fault in the
10 system. Maybe we should have regular formalised
11 reviews, but that is not the way it happened or happens.
12 Usually an issue arises and it would be wrong to
13 ignore it so you have to look into it. The example that
14 I am giving of the theatre sister is one way in which
15 one could get another angle on some sort of issue that
16 has been raised with you.
17 Q. So having had the issue raised, you then go and have
18 a chat with the theatre sister and discover the extent
19 to which there may or may not be force in the allegation
20 or the concern?
21 A. Yes.
22 Q. I will probably come back to that and pick it up with
23 you later, if I may.
24 Going back to paragraph 67 which is where we began
25 this discussion, the end of the fifth line:
0019
1 "We were given to understand that, whereas
2 referring cardiologists from outside Bristol sent urgent
3 and emergency cases to the BRI, as would be expected,
4 some non-urgent cases were sent elsewhere. Accordingly,
5 we believed that surgeons did their best with
6 a population of cases whose distribution may have been
7 skewed towards less favourable outcomes overall."
8 Just to see those two sentences in context, this
9 is an explanation which was given to colleagues;
10 presumably the "we" is colleagues, is it?
11 A. Yes, well -- yes, colleagues.
12 Q. This is an explanation given by the surgeons for the
13 fact that their service was, if I use the expression,
14 "only reasonable", it is giving back to you the word
15 you have used?
16 A. Yes.
17 Q. Who gave you to understand that?
18 A. I do not know. I could not give you names, but there
19 are people who could help the Inquiry from their direct
20 knowledge about these issues. I can only give it to you
21 as my recollection of the feeling that people had about
22 cardiac surgery in the BRI at the time.
23 Q. Give me the best of your understanding. Did the view
24 come from the surgeons?
25 A. I think so, definitely, yes. Definitely the surgeons.
0020
1 Q. Rather than the cardiologists?
2 A. The cardiologists -- you know that I do not refer to the
3 BRI cardiologists. The BRI cardiologists, I always
4 thought, were very loyal to the BRI cardiac surgeons,
5 although I do know that they did sometimes refer
6 elective cases elsewhere.
7 Q. Looking for the moment at who it was who was saying,
8 "Well, we get a rather different case mix from places
9 elsewhere, that is why our results are not quite so
10 good", which is what you are saying, is it not?
11 A. Yes, sure.
12 Q. Do you now have a view -- I suppose you have to accept
13 that your view today may be coloured by events of the
14 last ten years, but do you, nonetheless, have a view as
15 to whether it was the surgeons or the cardiologists or
16 the team as a whole from whom this view was coming?
17 A. Well, my view is coloured and it has to be, because
18 somebody took several thousand sets of case notes away
19 and counted up the outcomes, and I know what the
20 outcomes were. And, yes, my view has to be coloured by
21 that, because I have read the de Leval report and the
22 other reports on the outcomes.
23 Q. At the time in the 1980s, where do you think the view
24 "It is all because of case mix that we are not doing
25 any more than reasonably", was coming from?
0021
1 A. The reports which have caused me to change my view refer
2 to events in the 1990s, so I think if you confine the
3 question to my perception of the performance of the
4 surgeons in the 1980s, I think I would stick by the word
5 "reasonable". I do not think I have seen evidence to
6 show that their results were not reasonable in the
7 1980s.
8 Q. I am sorry, it is probably my fault; we are slightly at
9 cross-purposes.
10 What I was asking you was, you say in the sixth
11 line of your statement what you were "given to
12 understand"?
13 A. Yes.
14 Q. You were given that to understand by someone, whoever it
15 was. The view must have come, initially, from one or
16 other of two types of persons: a surgeon or
17 a cardiologist, I suggest?
18 A. Well, the person I am sure that I must have discussed
19 these things mostly with would be Mr Wisheart.
20 Q. So probably the view came from Mr Wisheart, did it?
21 A. Yes, but I would not think that that was a view that
22 could be ascribed solely to Mr Wisheart.
23 Q. I am simply asking for the best of your recollection,
24 that is all. That is all I am asking for.
25 A. I am sure he would not mind me saying it.
0022
1 Q. You say in the second of those two sentences which
2 I have been focusing on:
3 "We believe that the surgeons did their best with
4 a population of cases whose distribution may have been
5 skewed towards less favourable outcomes overall."
6 Again, the "we believed": who was the "we"?
7 A. Well, I certainly believed that, and I feel that amongst
8 the people that I tended to mix with and talk to in the
9 hospital, which are mainly surgeons, of course, I think
10 that was a prevalent view.
11 Q. Apart from the fact that Mr Wisheart, and no doubt
12 others, were saying, "we have a rather different case
13 mix", was there any other reason for coming to that
14 view?
15 Was it because he said that and you trusted him
16 and asked no further, or was it because there was some
17 objective, independent evidence of the case mix?
18 A. No, no, it was nothing like that. There was no
19 objective evidence of case mix or outcomes in the 1980s.
20 Q. So this was a question of Mr Wisheart and perhaps others
21 saying, "Our performance is no more than reasonable
22 because we have a rather more difficult group of cases
23 to deal with, so that is what you would expect."
24 A. I suspect he would have put a more positive spin on it.
25 He would have said "We would do rather better if we did
0023
1 not get the mix of cases coming our way at the moment".
2 Q. You mentioned a moment ago the fact that some of the
3 cardiologists, even in Bristol, despite their general
4 loyalty to the surgeons, referred some cases elsewhere?
5 A. Yes.
6 Q. I am going to ask you to do your best -- I appreciate it
7 may it not be easy -- to put some flesh on that for us.
8 A. They would say, I suspect, that the unit did not have
9 the capacity to deal with the workload that it was being
10 asked to deal with and that there was always spare
11 capacity elsewhere and that it was a convenience to
12 allow some of the cases that could go elsewhere to go
13 elsewhere. Of course, the cardiologists would be
14 discussing the matter with the patient, I suspect, and
15 there might be an element of choice given to a patient
16 and in the end he might have said "Do you want it to be
17 done in Bristol or London?" and the patient might say
18 "I think I will go to London".
19 Q. If the patient chooses to go to the convenient local
20 centre rather than the geographically less convenient,
21 to the London centre, presumably the decision would be
22 given to the patient?
23 A. No, I think if I had a patient sitting in front of me,
24 I would present it to the patient as one believes it, as
25 an evens choice. It might be a matter that the wait
0024
1 might be less in London.
2 Q. So it is a question of saying to the patient, "You can
3 be treated here but you will have to wait for longer, or
4 you can go to London and get the treatment sooner"?
5 A. That is possible, but with respect, you would be better
6 asking a cardiologist this. It is hearsay from me.
7 Q. It is none the less valuable for that, and I accept the
8 qualification that obviously you are relying upon your
9 memory of what has been said to you by others within the
10 hospital community as you describe it?
11 A. Yes.
12 Q. But you are doing your best, I have no doubt, to tell us
13 the reflection of what was being said. The fact that
14 cardiologists in Bristol, as you recall it, sent cases
15 elsewhere, that must be a fact?
16 A. I think it must be, yes.
17 Q. And if it is so, it is your best recollection of what
18 you understood the reasons to be?
19 A. Yes.
20 Q. And the reasons were that there was too great a workload
21 for Bristol to cope with?
22 A. That is my understanding.
23 Q. Was that in adult or in paediatric?
24 A. Well, the paediatric work was very widespread in its
25 origins, and I do not think we would always know --
0025
1 again, this is hearsay, but some of the cases would come
2 in through the Children's Hospital and some would be
3 referred by the paediatricians, where they were,
4 elsewhere. That is too remote for me to speculate on.
5 I do not know why. I do not know enough about the
6 pattern of referrals of paediatric cases.
7 Q. You cannot then help us, really, as to whether the
8 cardiologists who referred were dealing with adult cases
9 or with paediatric cases?
10 A. I think I should perhaps have made it clear that
11 predominantly adult cases was what I was talking about.
12 Q. That is what I suspect you would have said. The
13 position then as you recall it was, was it, that so far
14 as adults were concerned, there was a pressure for more
15 work to be done locally?
16 A. Yes.
17 Q. That the pressure was so great that some cases had to be
18 turned away, for very good reasons in terms of patients,
19 no doubt?
20 A. Yes.
21 Q. That the service as a whole -- I go back to the first
22 line in paragraph 67 -- suffered from underfunding and
23 therefore shortages of buildings, equipment and staff?
24 A. Yes.
25 Q. And it was acknowledged that although the surgeons were
0026
1 seen by many but not by all to be doing their best as
2 surgeons, the results were no more than reasonable?
3 A. Yes.
4 Q. Would you have a look at page 12 of your statement?
5 Perhaps I ought to take you back to page 11, I am
6 sorry. It is paragraph 45 and it is the opening words:
7 "'Evidence-based practice has always", and I will
8 come back to that word, "reflected our approach to
9 surgery, but now it is dignified by the phrase."
10 What is your description, because one does get
11 different descriptions of the phrase "evidence-based
12 practice", or "evidence-based medicine"?
13 A. I think to understand it you would have to go back to
14 the enthusiasm of surgeons to do things to people,
15 sometimes unsupported by the evidence, and you do not
16 have to look back very far in history to see that sort
17 of thing going on, and even today you see it in the
18 fields of cosmetic and aesthetic surgery. People are
19 making changes and the evidence base on which they are
20 proposing interventions to people is unsupported.
21 So I think certainly in teaching hospitals and
22 certainly in what we do so far as medical students are
23 concerned and trainee surgeons are concerned is that we
24 emphasise to them the need to have good reasons for
25 proposing any intervention on anyone. That is what
0027
1 I understand for "evidence-based". So if a bright light
2 is shone on what you do, you can justify your actions.
3 Q. So the "evidence-based", in the way you describe it,
4 means you have a good reason for doing what you do?
5 A. Yes.
6 Q. And that sounds more like rational practice, or practice
7 which can be rationally explained, rather than practice
8 for which there is documented evidence within the
9 journals as to the success rate or otherwise in dealing
10 with a particular clinician?
11 A. Well, the other words I was going to put in there is to
12 "worship at the alter of the randomised control trial",
13 because if you look at the quality of the evidence,
14 until you can randomise and then have two similar groups
15 and compare them after the intervention or not the
16 intervention and show a statistical and significant
17 difference between the two groups, then if you want
18 evidence base, that is the altar at which we worship
19 today. But there is a lot of people who do not do it.
20 You go there with general practice and you ask why
21 people are doing what they are doing; you do not always
22 get a very rational or evidence-based answer, but
23 because they are experienced they say "It works" and it
24 usually does.
25 Q. What you appear to be saying in paragraph 45 is that,
0028
1 by the word "always", you cannot, I suspect, speak
2 before 1977, when you became a consultant, but since
3 then, at any rate, you are saying that --
4 A. No, when I was a student.
5 Q. When you were a student?
6 A. Yes, they were on about it then, and I suspect -- you
7 know, you can go back a long time and still the teaching
8 would be based on good clinical practice, but there
9 would be people in practice whose practice did not
10 conform to what the profession regarded as soundly based
11 practice.
12 Q. And the "good" in "good clinical practice" might suggest
13 that there is some correspondence between the surgical
14 approach and the outcome for the patient in terms of
15 benefits?
16 A. Yes, but that is quite difficult to measure, to
17 quantify. I mean, it is a holy grail to do that for
18 every intervention. It is easier for some than others.
19 Q. Could I, having explored that, ask you to go to the top
20 of page 12 of your statement?
21 You say in the fourth line down that as Clinical
22 Director, so we are now looking at the period in the
23 early 1990s, you were aware that the cardiac surgeons
24 contributed their cases to the national cardiac surgery
25 register, although you never saw any reports of the
0029
1 Registry.
2 You go on to say the result would not necessarily
3 have meant a great deal to you. You go on to give
4 reasons for that.
5 As Clinical Director, with your responsibility
6 which you described to us for the performance of the
7 surgeons dealing with the particular cases, you knew
8 throughout the directorship that there was some sort of
9 objective, or apparently objective record being kept of
10 results?
11 A. Yes.
12 Q. Did you ever ask to see any of the results?
13 A. I do not think I could have laid my hands on them in any
14 meaningful way. I am not sure if it is Sir Terence
15 English's evidence here that I have read, but I know
16 enough about the cardiac surgical register to know that
17 the individual units entered cases and there was a lot
18 of anonymising went in, so I think it would have been
19 difficult to get a lot of sense out of the register.
20 But the answer to your question is, no, I did not ask to
21 see it.
22 Q. The register was plainly set up and run for a reason.
23 A. Yes.
24 Q. And there would be no point in a national register
25 collecting in information which it kept to itself and
0030
1 gave to no-one, because no-one would ever contribute
2 data to it, they would get it out the back?
3 A. Yes, but the reason was an index of activity. I do not
4 think it was set up for a regulatory reason because
5 I think here were the cardiac surgeons trying across the
6 country to develop good intervention rates for
7 a life-threatening condition and, because of the high
8 cost of their interventions, there was a reluctance for
9 the funding to follow it, and the only way they could
10 build their case is to prove to the authorities that had
11 the money what the levels of intervention were, and say
12 that where the levels of intervention were below an
13 acceptable rate investment had to be put into these
14 areas to bring them up to the levels of the rest.
15 So I think there are plenty of reasons for the
16 cardiac surgical register to be set up.
17 Q. Forgive me for putting it in my own terms and please
18 tell me if you think I have it wrong, but our
19 understanding here of the Cardiothoracic Surgical
20 Register is that it looked at a number of procedures,
21 identified the numbers done in a particular unit, and
22 nationally, and was able to say what the national
23 success or failure rate was in terms of outcome; in the
24 case of cardiac surgery it was death, the outcome?
25 A. Yes.
0031
1 Q. So one would be able to say, if you are having an
2 operation to transpose the great arteries, arterial
3 transposition, then nationally, within this age group,
4 in this particular year, the death rate is whatever
5 percentage it is?
6 A. Well --
7 Q. Is that broadly right?
8 A. Again, there were others who know more about this than
9 me, but it was my understanding that if you take
10 a procedure like blue babies within the first month of
11 life and if you take the palliative operation that the
12 surgeons were doing in the 1980s, which was called the
13 Senning operation, and if you take the anatomical
14 correction, which was called the switch operation in the
15 1990s, that the categorisation within the Registry was
16 insufficiently sensitive to distinguish between these
17 two approaches.
18 It is hearsay, but that is what my understanding
19 is.
20 Q. But have I got it right that it essentially looked at
21 a very broad definition, albeit of a surgical procedure,
22 and gave the national outcome in terms of percentage for
23 that particular procedure?
24 A. That is correct, yes.
25 Q. Given that, one would be able from a local perspective
0032
1 to say, "We have our own particular results, we know
2 what they are, obviously nobody else does because they
3 are anonymised nationally, but we know what they are, we
4 can compare what we are doing with what the rest of the
5 country appear to be doing"?
6 A. My understanding of that is that the results were always
7 regarded as within the acceptable range.
8 Q. What do you base that understanding on?
9 A. I do not know. I mean, the people I talked to, the
10 discussions that went on at the time. I think they only
11 really got to the root of the poor outcomes in children
12 when a third party took the case notes away and
13 independently analysed them. That was what convinced
14 me.
15 Q. Leave that aside for the moment. What I am asking about
16 is the time that you were actually Clinical Director.
17 A. Yes.
18 Q. What I think you have told us is that you knew there was
19 the cardiothoracic register and that broadly it took
20 broad descriptions of operations and provided national
21 success rates?
22 A. Yes.
23 Q. That it provided a measure of comparison, leaving aside
24 for the moment the --
25 A. Activity, mainly.
0033
1 Q. Activity?
2 A. Yes. Process rather than outcome. The league tables
3 were often expressed in these terms, as I said to you
4 earlier, the one that I saw in the BMJ in the 1980s
5 showing the South West having the lowest number of
6 cases. That always concerned me a lot.
7 Q. You told us that those to whom you spoke conveyed the
8 impression to you that so far as outcomes were
9 concerned, Bristol was no better and no worse than other
10 places in the country?
11 A. Yes.
12 Q. What I was asking you, and you went on to describe later
13 events, which obviously have coloured your recollection,
14 but what I was asking you was, who told you, so far as
15 you can recollect, that the results were no better and
16 no worse?
17 A. Well, again, I am sure I must have talked to James
18 Wisheart about these things. He was almost
19 a contemporary of mine, he is a few years older than me,
20 and he was in a position of leadership in the hospital,
21 and when I was Clinical Director, he was the Associate
22 Clinical Director for cardiac surgery, so I am sure
23 I would have discussed these matters with him.
24 Q. So again, in this area, just as when we were looking at
25 the question of the performance during the 1980s, you
0034
1 were relying upon what was being said to you by others?
2 A. Yes, very much. If you look at it today, if you look at
3 it in my time as Medical Director, where these
4 regulatory measures are much more well-developed, if you
5 take the example of the laboratories, for example, the
6 laboratories where they measure things in test tubes and
7 so on, they are sending blanks and samples around the
8 country and there is a lot of laboratory accreditation
9 going on constantly to verify the quality of the
10 laboratory outputs, and I know that this is going on,
11 but I have never seen any of the reports; I just know
12 that I have heard the results are satisfactory.
13 So all around the hospital, nowadays, that kind of
14 quality assurance is taking place, but we do not have
15 the mechanism present, even now, to have the opportunity
16 to review these personally; you have to rely on others
17 drawing these matters to your attention.
18 Q. I wondered if you might say that, because the way in
19 which the system worked, as you have described it, is
20 that although you had the responsibility for the care of
21 the patient, in deciding the success or failure or
22 relative acceptability of outcomes in a field such as
23 paediatric cardiac surgery, you relied upon what the
24 surgeons in that specialty were able to tell you?
25 A. Yes. It is a common fiction that audit is the cure to
0035
1 all of this and that if you count up everything you do
2 and analyse it scrupulously, that you will gain some
3 knowledge that will allow you to judge people in terms
4 of their clinical competence. I would not want the
5 Inquiry to get any sense that this is (i.e. Audit)was some sort of
6 solution to all of this. I mean, in the absence -- in
7 our imperfect world -- of that kind of answer, you have
8 to rely on other indices, other things like critical
9 incident analyses, like complaints, like medico-legal
10 claims. It would be lovely if you could count
11 everything and prove that things were good or bad on the
12 basis of counting, but I fear that is not true.
13 Q. It goes back, does it, to what you said about half an
14 hour ago: that your role was essentially reactive rather
15 than proactive?
16 A. Yes, absolutely.
17 Q. So you have to have a reason to look at something before
18 you would do so?
19 A. Yes, of course, absolutely.
20 Q. It may be -- tell me what the answer is -- with the
21 benefit of hindsight, and those are critical words in
22 this question I am about to ask you: with the benefit of
23 hindsight, you may wish that when you had been Clinical
24 Director you had asked for the figures and asked for an
25 explanation of what the returns to the cardiothoracic
0036
1 register showed?
2 A. Yes. If you wind the clock forward to when these
3 matters came out into the open, James Wisheart and
4 Janardan Dhasmana are on the record as defending their
5 results, right up until the GMC Inquiry. If allegations
6 are made against somebody, you have to listen to the
7 answers that the person gives. Nowadays we might run
8 things differently, we might commission somebody to take
9 a pile of case notes and go away and analyse them, but
10 certainly, I know of no circumstance in which that would
11 ever have been contemplated at that stage.
12 Q. Is it the case that if you had been able to know what
13 you know now with the benefit of hindsight, that you
14 wish you had asked some more questions earlier?
15 A. Of course. I think this has been an absolute tragedy
16 and the loss of public confidence in the hospital is
17 something that -- I mean this hospital has been present
18 for 260 years, since 1737, and it has had its share of
19 problems and the history of the Bristol Royal Infirmary
20 that was written at the end of the nineteenth century
21 describes some things that happened in the early days
22 that caused the people of Bristol to protest about what
23 was happening in the hospital. And there were ways in
24 which these matters were dealt with. So what has
25 happened here is another example in the long history of
0037
1 the hospital of something which has caused us to lose
2 the confidence of the public we serve and that is
3 terrible. That will take us a long time to regain.
4 Q. You mentioned a moment ago that Mr Dhasmana and
5 Mr Wisheart defended their position right up until the
6 GMC?
7 A. Yes.
8 Q. And I do not want it to be misunderstood beyond this
9 hearing chamber that the questions which I have been
10 asking and the explanation which I have taken of your
11 evidence implies on the part of the Inquiry any
12 viewpoint as to what the results should be. We have not
13 heard from them yet; we have not had our own statistical
14 analysis reported to us, so may it please be
15 understood -- I am addressing the wider audience here
16 rather than you -- that there is no prejudgment in the
17 questions which I am asking you. But what I want to
18 explore with you is, having secured your answer which
19 you gave me a moment ago, that with the benefit of
20 hindsight, yes, of course you wish you had asked some
21 more questions and it may follow, the answer to this
22 next question, from what you have been saying to us.
23 Turning the clock back, putting yourself into the shoes
24 which you were filling in 1992/93, why is it you think
25 you did not?
0038
1 A. I do not know if people understand quite how much work
2 is involved in doing the kind of study that would be
3 required to provide the information that would be
4 needed. The cases would have to be identified; they
5 would have to be complete. Someone would have to go
6 through the operating book to find them. They would
7 have to be stratified by age and sex and risk. The
8 procedures would have to be carefully defined. I know
9 that, for example, some of the procedures in the
10 preliminary analyses that led up to the GMC Inquiry had
11 certain of the cases misclassified, and having written
12 150 papers on vascular surgical topics doing this sort
13 of thing, I was not about to volunteer. I do not know
14 if I would volunteer now. It is an extremely expensive
15 and time-consuming business, as I am sure the Inquiry
16 team is finding with a group of experts.
17 Q. I do not mean to belittle the answer you have given me,
18 but I hope to express it, and tell me if this is right:
19 what you are saying is that if you had thought about it,
20 that as it happens, you would not have had the time
21 available yourself to deal with it?
22 A. Well, I would not personally, of course not, but look at
23 when these various outside enquiries came in. There was
24 an unlimited budget. Research assistants were hired,
25 computer programmes were written. I do not think
0039
1 I could have found money in the budget to create that
2 kind of investigative group.
3 Q. So given a situation, let us suppose -- and this is
4 moving from the actual to the theoretical -- given
5 a situation in which, let us suppose, there are grounds
6 for concern about the results of a couple of surgeons;
7 that those surgeons for their part stoutly maintain that
8 those results are perfectly acceptable, are you saying
9 that really in the world as it was in the early 1990s,
10 there was no easy way of resolving that particular
11 difference of view?
12 A. Yes. Or today, for that matter. What you have to do is
13 you have to isolate the accuser, you have to isolate the
14 accused. You have to take some independent parties with
15 knowledge of the area and then you have to give them the
16 resources to consider the allegations and provide you
17 with evidence to either confirm or refute the
18 allegations that have been made against them.
19 Q. So since there were no resources available, which is
20 what you are saying, I think, to do a job such as this
21 as a matter of routine reaction, how would the system
22 have dealt with the question of clinical competence
23 before, let us say, 1993/94, in the case of a consultant
24 as opposed to the case of a trainee?
25 A. I think it would have done so with great difficulty.
0040
1 I think there are three aspects of a consultant's
2 activity: health, conduct and competence. You have
3 addressed all the discussion to competence as the
4 relevant issue in this case. The hospitals have always
5 dealt with the health and conduct issues of their
6 consultants as best they could and when consultants have
7 transgressed in the areas of conduct and when
8 a consultant's health has been poor, there are
9 consequences of these things happening.
10 In terms of competence, the difficult area arises
11 where the individuals lack insight. If the person has
12 insight into an area of competence, you get a round peg
13 in a round hole and the person stops doing whatever it
14 is that they do not do particularly well. Where the
15 person lacks insight, then you have to move up apace and
16 I do not remember, in my career in medicine -- although
17 I would not know, of course, because you do not hear
18 about these things -- but I think that it was difficult
19 for competence to be looked into.
20 Q. You draw attention in the course of your statement to
21 one particular case, when you were, I think, Medical
22 Director. Forgive me for a moment while I see if I can
23 find it: it is page 6, paragraph 23.
24 The last four lines:
25 "In my time as Medical Director, I had occasion to
0041
1 inform the RMO, Dr Scally, that we had dismissed a locum
2 doctor because of clinical incompetence. The details
3 were passed to the GMC".
4 You make specification mention of that. This is
5 your time as Medical Director, which is what, 19 --
6 A. 1996 to 1999.
7 Q. So as late as 1996 to 1999 you make a point of saying
8 "We did dismiss one doctor for clinical incompetence".
9 Was there any other case in which you were involved
10 where a doctor was dismissed for clinical incompetence?
11 A. No, no dismissal, although the Inquiry will know that
12 the Chief Executive and I dismissed Mr Dhasmana.
13 Q. Yes.
14 A. But we have looked into allegations about the conduct of
15 consultants in about 12 of 240 consultants, which is
16 5 per cent.
17 Q. Conduct or competence?
18 A. Well, that is all three: health, conduct and competence,
19 but amongst these 12, there have been three or four
20 cases in which we have investigated competence in the
21 last couple of years. That is why I can answer to you
22 the way that I have in terms of the accused and the
23 accuser, because we have done it.
24 Q. Before 1996, before the events which gave rise to this
25 Inquiry, when you were Clinical Director, did you know
0042
1 of any case in which competence was the reason?
2 A. No, no, I do not think so.
3 Q. I am grateful, I am told paragraph 59, page 16.
4 A. Yes, the last sentence there.
5 Q. "There could have been such investigations but I would
6 not have been aware of them because they were
7 deliberately kept confidential."
8 That would be the case, presumably, if the concern
9 about competence was passed in confidence to one of the
10 "three wise men" and they kept it to themselves?
11 A. Yes.
12 Q. But it would suggest that in such a case, where there
13 were concerns about competence, the grapevine did not
14 transfer any information to someone such as you?
15 A. Yes. I cannot over-emphasise the importance of the
16 grapevine to me as Medical Director. I have learned
17 that if I hear something, the one thing I cannot do
18 is -- well, not any more -- I could not ignore it;
19 I think I have to find out whether there was any
20 substance to it or not.
21 Q. It gives rise to the question: albeit that these matters
22 were supposed to be confidential, do you think if there
23 had been a concern about competence, you would probably,
24 by and large, have become aware of it simply through the
25 grapevine, being as you were an established and trusted
0043
1 consultant?
2 A. I do not know. You see, in any profession, there are
3 people with different qualities. If one thinks of the
4 people one knows, whatever one does, and usually they
5 end up doing what they are comfortable doing, but the
6 issue is the lack of insight of the individual. It is
7 independent clinical practice. The doctor is treating
8 a series of patients and the whole issue of the
9 confidentiality of it is not to undermine the confidence
10 of the patient in the doctor who is seeing him. That is
11 the most precious thing that we have, as doctors; we
12 have to have the confidence of our patients.
13 So if someone has a question about somebody's
14 competence, it is not in anyone's interests for that to
15 be looked at anything other than in confidence until the
16 facts are established one way or the other.
17 Q. I think the confidentiality to which you are referring
18 is confidentiality amongst clinicians?
19 A. Yes.
20 Q. As opposed to telling the patient. What I was asking
21 in terms of the "grapevine" was, given that the
22 grapevine gives lots of information about other
23 clinicians which is not available to the general public
24 because it is within the "club", if you like, might you,
25 do you think, have expected to hear within that context
0044
1 if a fellow consultant had in fact lost his job or
2 changed his role because of suspicions about his or her
3 competence?
4 A. I think by and large the senior people get to hear about
5 these things. And remember, even in the early 1990s,
6 I was not the senior surgeon, and my senior
7 colleagues -- I mean, it is like the senior partner or
8 the head of chambers or somebody. If something is going
9 down, the person to whom people go is usually the senior
10 person and unless you are involved, if you are a junior,
11 it is not really much of your business. That is what
12 I feel.
13 MR LANGSTAFF: I have taken you past the break time because
14 the answers you were giving were important to have at
15 that time. Sir, I am sorry about going on a little
16 bit. May we perhaps take a break now for 10 minutes or
17 a quarter of an hour?
18 THE CHAIRMAN: Shall we say 15 minutes and that will take us
19 through to 2.40? Thank you.
20 (2.28 pm)
21 (A short break)
22 (2.45 pm)
23 MR LANGSTAFF: I am now going to ask you about something
24 rather different: the management structures which
25 applied during the time you were Clinical Director and
0045
1 latterly the Medical Director.
2 Can we look at document UBHT 98/214.
3 Can we scroll down a bit, please? This is
4 a minute of 1990, 18th July. Dr Roylance is reported,
5 under 67/90, in the last full paragraph under "Medical
6 directorates" as saying that he felt as General Manager,
7 the management structure was his responsibility alone.
8 Pausing there, was that the way in which his view
9 came across to you?
10 A. I am sure he took responsibility for it, but from my
11 knowledge, he was well-supported in reaching the view
12 that he took on management structure and he would defend
13 it. I do not think he conceived it; I think he took
14 a lot of advice and thought about it quite hard and
15 worked out what he thought would work. Once he had
16 decided what he thought was right, then he would defend
17 it against people who sought to sway him from the view
18 that he had taken.
19 Q. The reason why I start this part of my questioning there
20 is really because of what you say in your statement at
21 page 4. Can we have a look at that? It is
22 paragraph 15, where you are talking about the Hospital
23 Medical Committee providing a voice directly to the
24 Chief Executive, but it is the last sentence: the HMC
25 giving Dr Roylance a feel for what the consultants were
0046
1 thinking and as it turned out, an opportunity to nip in
2 the bud any opposition, the words you have chosen, "to
3 his plans for the Trust."
4 So you see him in 1999, when you write this
5 statement, as being his plans?
6 A. Very much so. The person who wrote them was Kate
7 Orchard, but she wrote them at his behest. And, of
8 course, if you sit at the top of a Trust and you have
9 a very large organisation that has 5,000 or 6,000
10 people, you are trying to get the message down into the
11 Trust and there are always a few wayward souls who
12 either oppose for the sake of opposing or for some other
13 reason, but in the end, if you are the Chief Executive
14 or whatever and you work out how it has to happen,
15 obviously you listen in a reasonable way to what other
16 people say, but in the end, you are responsible for it and
17 if you allow yourself to be swayed by somebody who
18 suggests something else and you are persuaded against
19 your better judgment to do it differently and then it
20 goes wrong, then you feel a bit of a fool and you say to
21 yourself, with hindsight, "I wish I had stuck to my
22 guns".
23 I suspect he worked out with his management team
24 what the best deal was going to be for us, and then he
25 had to sell it to us. Maybe that is another way of
0047
1 expressing it.
2 Q. How dominant a character would you say he was, in
3 management terms?
4 A. Quite dominant. You have seen him here.
5 Q. We have not had the opportunity to see him in operation,
6 and you have of course, which is why I asked you the
7 question.
8 A. I can remember him back in the 1970s leaning against the
9 door jamb in the x-ray department feeling very strongly
10 about how the hospital should be run. He was just
11 a radiologist. He has always been very committed to try
12 and run the place as well as he could.
13 Q. Your particular role as Clinical Director, can we have
14 a look at a document from 1991, UBHT 110/636.
15 I will just read it out, because we will go back
16 to the page in a moment -- in fact we can probably go to
17 split screen. Can we have WIT 75/4 on the left-hand
18 side? This is really to show off the technology!
19 If you look at the top of the page, paragraph 13,
20 you say that you personally, as Clinical Director, were
21 regarded as the Chairman of the directorate?
22 A. Yes.
23 Q. You regarded the General Manager as the Chief
24 Executive. Your role was to deliver the surgical
25 consultants in terms of their clinical contribution
0048
1 within the hospital and you say you had a line of
2 responsibility for clinical matters to the Chief
3 Executive.
4 A. Yes.
5 Q. Perhaps for the sake of clarity for those whose vision
6 is not as good as mine is close to the screen, we had
7 better go back to single screen on the right-hand side:
8 "The role of Clinical Directors."
9 This is May 1991, so it is just after the Trust
10 begins.
11 "Mr Dean Hart reported that he had felt it
12 important for Clinical Directors to be able to discuss
13 how they saw their role in the new management structure
14 and to be able to voice any concerns about the role of
15 management. For this reason, he had not invited senior
16 managers to attend this meeting. He reminded members
17 that they had been appointed by Dr Roylance as Chief
18 Executive of the Trust and as such they were responsible
19 for the negotiation, maintenance and delivery of
20 contracts."
21 That is rather more than clinical matters?
22 A. Yes. It is quite difficult. Clinicians are by and
23 large enthusiasts who are interested in treating
24 patients and education and research, and trying to get
25 them interested in running a big institution like
0049
1 a hospital takes a bit of effort. He would feel, and we
2 would feel it today, that unless the clinicians owned
3 the contracts, when things needed doing on the
4 contracts, the clinicians would distance themselves from
5 it. So the only way to get the clinicians involved in
6 the management is to try and suck them into the process
7 so that they owned it, and owned it now.
8 Q. So although you were never trained as a manager, here
9 you were being given a management role?
10 A. Sure.
11 Q. I have assumed you were not trained as a manager?
12 A. No, absolutely not.
13 Q. And then to the description you give in your statement
14 of being responsible for clinical matters to the Chief
15 Executive, you would have to add responsibility for the
16 matters set out here in this minute, would you?
17 A. Well, I would own them, but the managers with whom
18 I worked, I mean, you have heard their names, Margaret
19 Peacock, Kate Orchard and Janet Maher, they dealt with
20 the purchasers, who were Deborah Evans and Linda
21 Williamson, and the detailed number-crunching of the
22 contracts was done by our managers and was negotiated
23 with their managers.
24 I felt my job as Clinical Director was to act as
25 a sounding board for the managers to make sure they got
0050
1 it right and before they went to negotiate the contracts
2 with Avon, to, you know, have them run what they were
3 proposing past me and see if it sounded right and see
4 what their anxieties were about what they were proposing
5 and what deal we thought we could do. But, I mean, I am
6 a surgeon, I am seeing patients and operating. I cannot
7 do the number-crunching, but I can support them and
8 I can defend what they do in the directorate to my
9 colleagues.
10 Q. The minute goes on:
11 "However, should Dr Roylance be succeeded by
12 a non-medical Chief Executive, the whole balance of
13 management would alter and there would need to be
14 medical advice to whom Clinical Directors could refer."
15 A. And so it happened when Hugh Ross took over.
16 Q. Yes, but what I am interested in is this view expressed
17 as it was in 1991 that there was an effect on the way in
18 which the whole Trust was managed by virtue of the very
19 fact that Dr Roylance was medical rather than
20 non-medical. That is what is being said, is it not?
21 A. Yes. I think that is right. I think perhaps with
22 hindsight the clinical aspects of it would have been
23 better to be more broadly based. I mean, he was rather
24 like a ballbearing between two tectonic plates which
25 were grinding away at him. I think in the longer term
0051
1 a more broadly based structure is perhaps better, but
2 that is a judgment of hindsight. The advantage of the
3 way he did it was that he delivered us as a first-wave
4 Trust and he persuaded his clinical colleagues, us, to
5 embrace at an early stage this very fundamental
6 separation between purchasing and providing, and you
7 will remember that at the time it was viewed with great
8 scepticism; it was the brainchild of Ken Clarke when he
9 was Secretary of State and it was viewed with great
10 suspicion, and I think William Waldegrave, who was our
11 local MP here and was also Secretary of State, to try
12 and help the implementation. He said that it was
13 reasonable to know what was being done and how much it
14 cost, and that was the separation. It was a pretty
15 fundamental change in the way the Health Service was
16 run.
17 Q. In that lovely example you gave of the ballbearing
18 between two tectonic plates, can I be clear so there is
19 no misunderstanding what the "tectonic plates"
20 represent?
21 A. To me, they represented on the one hand the
22 within-hospital bit, the consultant body, the senior
23 nurses and the hospital community, and on the other hand
24 it was those who gave us the money, which is the
25 purchasers. You see, we needed to safeguard the income
0052
1 stream into the hospital because otherwise we would have
2 had to sack people.
3 Q. Why did it make a difference, Dr Roylance being medical
4 as opposed to non-clinical?
5 A. The National Health Service oozed out of him. He had
6 his whole life in it. He knew it backwards and he had
7 the advantage he was dealing with several lay managers
8 who had been brought in to run this purchasing
9 authority, and he could sort of encourage them to do the
10 right thing, sometimes.
11 Q. You mean he was a good negotiator for the Trust?
12 A. Quite.
13 Q. And the balance of that would shift as it did when Hugh
14 Ross took over, this is some years before, so what do
15 you think Mr Dean Hart had in mind by saying, "Well, if
16 he was not a medical man, we would do it differently",
17 which is in effect what he is saying -- "We have to do
18 it differently", I think is what he is saying?
19 A. Yes, absolutely.
20 Q. Why would one have to do it differently simply because
21 the non-clinical Chief Executive would not have medicine
22 oozing out of his pores?
23 A. Well, I do not wish to be flippant, but do you remember
24 the Italians voted for Mussolini because "at least he
25 made the trains run on time"? The great thing about
0053
1 John Roylance was that at least we all knew where we
2 stood. Quite honestly, most of the clinicians just
3 wanted to get on, and still do, with treating the
4 patients. If they trusted him, as we did, and he said
5 this was the way to go, then with one or two exceptions,
6 which he was able to deal with, he was able to get his
7 own way. And maybe that was not a bad thing.
8 Q. That did not work entirely. When it came to the
9 question of Trust status, the votes in terms of
10 consultants were against?
11 A. Yes.
12 Q. Rather than for, I think. But Trust status came
13 nonetheless?
14 A. That is right.
15 Q. So it was not just a question of everyone saying -- and
16 no doubt they may have trusted John Roylance although
17 they did not take his view on that occasion?
18 A. Yes.
19 Q. Again, if I can come back to press you on whether you
20 can help, really, with the views that were being
21 expressed here, why does the fact that he is a medical
22 man, albeit that may mean that people trust him, why
23 does that make such a difference?
24 A. It made more of a difference, I think, when he dealt
25 with the lay bureaucracy than when he was dealing with
0054
1 the professional groups. There are a lot of lay managers
2 out there. He is an imposing looking man and he could
3 project himself and we felt he would go in to bat for
4 the Trust and we would be okay if he was there and doing
5 it.
6 Q. That is your Mussolini example?
7 A. Yes.
8 Q. "He is a powerful figure who may do the job"?
9 A. Yes.
10 Q. That owes a lot to his character, but again, I come
11 back -- it may be that you cannot help, but the
12 character of a man and the fact that he is a medic are
13 not necessarily linked?
14 A. No, well --
15 Q. Here the point made by Mr Dean Hart is that it is
16 because he is a medic. If he was not a medic, we would
17 have to do things differently?
18 A. I accept that point.
19 Q. And I was really wondering whether you could shed any
20 more light on why, if he was not a medic, things would
21 have to be done differently?
22 A. No -- well, yes -- well, now we are in a completely
23 different circumstance. We have a lay executive. He is
24 a super person, a broadly based consultative management
25 structure, we work in a very complex bureaucracy where
0055
1 every penny of money has to be bid for one way or
2 another. He has people who can make cases for this,
3 that and the next thing, and he does it in a different
4 way. I am sure if John Roylance had not been there in
5 1989 or 1990, there would be some other leader who would
6 have emerged that we would have been glad to follow.
7 Q. I will not press it, save to say this: when you go away
8 today and you think back over this particular part, as
9 you are bound to do, if you have any insight into why
10 the fact that someone is a doctor or not a doctor
11 should, of itself, make a significant difference to the
12 way in which the Trust is run, so it could not be run in
13 the same way, can you put it down on paper and let us
14 have it, please?
15 A. Yes, of course.
16 Q. Because it is not here put forward -- maybe it has been
17 missed out -- but it is not put forward as a matter of
18 character and it is not put forward as a matter of
19 simply one person's style being different from others,
20 as it is perhaps bound to be?
21 A. Maybe Mr Dean Hart could shed some light on it.
22 Q. It may be. If you have any further thoughts, perhaps
23 you would let us know?
24 A. Of course I will, yes.
25 Q. If we could have a look, please, at page 637, and can
0056
1 we scroll down and go back up again?
2 A. I imagine this is the HMC?
3 Q. I think it is, yes. It is the second paragraph of the
4 page:
5 "Dr Watt referred to the direct line management
6 responsibility of Clinical Directors to the Bristol
7 provider operations manager and said that he [Dr Watt]
8 would prefer to be accountable to a Medical Director."
9 So this is the origin of the line of division
10 between the medical side and the management side, is it?
11 A. He is saying he would rather talk to John Roylance than
12 Margaret Maisey.
13 Q. Yes, because she was a manager and he was a doctor.
14 Have I got it right or not?
15 A. I am certain you have got it right.
16 Q. It goes on, halfway down the page:
17 "Dr Watt said he felt strongly about the
18 directives being issued by management, particularly with
19 regard to the ..."
20 He deals with a number of matters, some of which
21 are bureaucratic, perhaps, and was assured by Mr Dean
22 Hart that Mrs Maisey would in future liaise direct with
23 directors, not managers.
24 What is happening here? This is the early days of
25 the Trust and Dr Roylance was at pains to emphasise how
0057
1 things did change.
2 A. You might call it a little "muscle flexing" from
3 Dr Watt.
4 Q. He was flexing the muscles of the clinical side, was he?
5 A. Yes. Maybe Mrs Maisey had made some gentle suggestion
6 to him that he might not entirely have gone along with.
7 Q. And the suggestion here is that she had the route
8 through to the managers, the managers responsible to
9 her?
10 A. Yes.
11 Q. This is Mr Dean Hart saying in future she will talk to
12 the directors rather than the managers?
13 A. Yes: it is very difficult because we doctors are not
14 very good as managers at running a business. In the end
15 the moral duty of an institution of the State is to
16 balance the books at the end of the year. We doctors
17 are very good at overspending and the managers are very
18 gently making sure that in the end the numbers turn out
19 right at the end of the year.
20 Q. Can we have, in the light of that last answer, a look at
21 UBHT 110/107?
22 Can we move down, please?
23 "Report of the Medical Director". This is 1992.
24 "Arising out of recent discussions at the Steering
25 Committee it was considered that all consultant job
0058
1 descriptions should contain standard paragraphs relating
2 to commitment to teaching, the encouragement given to
3 research, and" and these words follow, "their managerial
4 responsibility to their Clinical Director."
5 A. Yes.
6 Q. What that appears to be envisaging was that the
7 consultants themselves were to be managers to an extent?
8 A. Well, Clinical Directors.
9 Q. But this is talking about consultants having managerial
10 responsibility to the Clinical Director who had himself,
11 as you told us, a managerial responsibility?
12 A. I mean, I do not want to rewrite the paragraph, but
13 should it not read "and they should be managerially
14 accountable to their Clinical Director"?
15 Q. You may well be right. This is one of the advantages of
16 having somebody who was there who can tell us how things
17 worked.
18 A. Because you see, you have clinical accountability which,
19 if you treat the patient wrong, you get a complaint or
20 a claim against you, or whatever, and then you have
21 managerial accountability in which you are a team player
22 within a group who are sharing a lot of common assets.
23 I do not know who wrote the minute, but I think if I had
24 been writing it, I would write it as "managerial
25 accountability".
0059
1 Q. So in what respects was the consultant going to be
2 accountable to you in a managerial way?
3 A. Lots of things, all the sharing things. The consultant
4 would say, "They have closed some beds on my ward", you
5 know, "So-and-so has taken the nurses away and put them
6 somewhere else", or "My operating theatre list had to be
7 cancelled", or some such thing, or "Somebody from
8 another specialty has their patients in my beds."
9 There are all sorts of "turf" issues which are at a distance
10 and are remote from the doctor/patient relationship. It is
11 a bit like an airline pilot. Nobody disputes the
12 autonomy of the pilot in the aeroplane in the air, but
13 the moment the pilot gets on the ground, he is a company
14 man.
15 Q. I have dealt in that minute with the way in which the
16 consultant and you were dealing with each other in
17 respect of management issues. You say that they were
18 largely "turf" issues. When you became the Medical
19 Director, were Clinical Directors responsible to you in
20 the same way?
21 A. I am not sure about that. The most public way that the
22 accountability is shown is in the monthly meeting of
23 Clinical Directors, and I think it is significant that
24 that is chaired by the Chief Executive and not the
25 Medical Director. And also, the regular performance
0060
1 reviews of the directorates are conducted under the
2 Chairmanship of the Chief Executive.
3 If you even look at the latest guidance from the
4 Department of Health, the responsibility for the quality
5 of the service that is delivered rests with the Chief
6 Executive; it does not rest with the Medical Director.
7 The Chief Executive is the Chief Executive Officer of
8 the Trust, so I have always viewed there being
9 a professional agenda which is led by the Medical
10 Director and the nursing director at the Trust Board.
11 That is the way I would see it.
12 Q. Sticking just for a moment with the Clinical Director --
13 I am going to come on to the Medical Director in
14 a minute and ask you about, again, some of the minutes,
15 which may need a bit of explanation. Can we have a look
16 at 110/724? 23/91 is the minute. This is a minute of
17 2nd February 1991.
18 "Members were reminded that payments for sessions
19 of managerial time over and above clinical time or of
20 locums for Clinical Directors could only be made from
21 within the directorate budget."
22 Clinical Directors had relief, did they, from
23 their clinical duties in terms of not having to do
24 sessions per week -- some sessions?
25 A. Well, most of them did what they did before and just
0061
1 worked a bit harder. I mean, some of them gave up
2 something.
3 Q. That is what I was going to ask you. Here it would
4 mean that a Clinical Director could only take payment
5 for the work he did as Clinical Director at the expense
6 of his directorate budget?
7 A. Yes, and I think that is probably true today too.
8 I should say that I never asked for nor received any
9 enhancement to my salary as Clinical Director.
10 I thought it just went with the job. I think it has
11 changed now and I think people get one or two sessions
12 for doing it. I think it is routine now, but it was not
13 routine in 1989 or 1990.
14 Q. So in 1989/90 the rule, rather than the exception, was
15 for people such as yourself to work in effectively your
16 own time and for nothing?
17 A. I can only speak for myself, because I know that other
18 people, even Associate Clinical Directors within my
19 directorate, accepted extra sessions to do that work,
20 but I chose not to and it did not bother me much.
21 The way I did it was it just so happened that the
22 directorate office was across the corridor from my own,
23 and I would pop in for a few minutes and see how they
24 were getting on. I was in there, maybe twice a day just
25 for five or ten minutes. They would be doing the work
0062
1 and I would just keep an eye on them, and they would
2 tell me what they were worried about and what the issues
3 were. Of course there were regular meetings that had to
4 be gone to, and you will know that consultants' fixed
5 sessions are only a portion of the week. Traditionally
6 we have, if the week is considered 11 half days, which
7 is what it is in contract terms, perhaps about half of
8 that is fixed and the other half is flexible for things
9 like emergency duties, administration, teaching,
10 research and so on. I used to fit my work as Clinical
11 Director into that time. And even if I was, for
12 example, as I was this morning, at a fixed clinical
13 session, you can still pop in and keep things going
14 in-between times. You can keep the kettle boiling, you
15 know.
16 Q. So what you are describing is a situation in which
17 people, because they were working for the greater good,
18 would carry out a full clinical load and do whatever
19 work they may have had as Clinical Director on top?
20 A. Yes, or you might -- you know how there are trainees
21 around; you might get a bit of help from a trainee. We
22 might have a clinical research fellow. If, for example,
23 there was a meeting with the purchasers and it just so
24 happened I have an outpatient clinic that afternoon,
25 I would get the research fellow to come down and do it
0063
1 for me, so I could go off and talk to the purchasers, or
2 something like that. But most clinicians tried to keep
3 their fixed sessions free (for clinical work).
4 Q. You used the expression a moment or two ago that you
5 would "pop over" to the office?
6 A. Yes.
7 Q. And they would tell you what the issues were, the issues
8 of the moment?
9 A. Yes.
10 Q. They being --
11 A. The General Manager of the directorate and the Associate
12 General Managers, so there were maybe three or four of
13 them.
14 Q. They are full-time engaged in management?
15 A. Exactly.
16 Q. So the picture would be that the clinicians are
17 full-time engaged in clinical practice?
18 A. Yes.
19 Q. But they have responsibility for the directorate?
20 A. Yes.
21 Q. And the way you described it, it is a sort of policy
22 Chairman type role. That is in fact how you put it in
23 your statement.
24 A. Yes.
25 Q. The nitty-gritty is dealt with by the General Manager?
0064
1 A. Sure.
2 Q. The General Manager and the Associate General Manager
3 know what is happening all the time?
4 A. Yes, and remember, they are the budget holders. I mean
5 I never knew a budget number. They would not let me,
6 because I might spend the sum of money.
7 Q. Even though you had the responsibility for it?
8 A. Yes. I never knew what the budget numbers were.
9 Q. So you left that to them?
10 A. Well, I tried to get little things. I would say to
11 them, "Come on, why don't you get one of these?" and
12 they would look at me rather sceptically and it would
13 either come or it would not.
14 Q. You were not really in a position to say, "We have got
15 œ500 in the budget left and this is --
16 A. No. In my career in the Health Service, I have never
17 been accountable for a budget. I have never been
18 a budget holder.
19 Q. When you went across there and they told what you the
20 issues were, they would be the people with the intimate
21 knowledge of the issue?
22 A. Sure. They are at it all the time. They are
23 full-timers. They are pros at it. Remember, we are
24 a big business. My directorate had a turnover of
25 œ20 million a year and that General Manager was looking
0065
1 after that budget and in the words of our Director of
2 Finance, at the end of the year it is "like landing
3 a jumbo jet on a sixpence" and they were bringing in the
4 financial responsibilities so that on 30th March we were
5 right.
6 Q. In terms of the issues which they were telling you
7 about, there is a view, certainly, that in many quarters
8 knowledge itself, detailed knowledge, is power.
9 A. That is true.
10 Q. So effectively you are describing, are you, a situation
11 in which the General Manager in the directorate had the,
12 if I use the quotes around the words, the "real power"
13 and the Clinical Director had the "nominal
14 responsibility"?
15 A. Well --
16 Q. I put it rather starkly. How accurate is that?
17 A. I always have regarded it as a partnership. I do not
18 think either of us can do without the other. Together
19 we can achieve more than either of us individually.
20 Q. And the roles are as you described, their role to have
21 the fund-holding, the information, the finger on the
22 pulse to brief you; your job when you did the job --
23 A. Their role was to get the money and spend it wisely. My
24 role was to make sure that on the clinical side of
25 things, everyone got on together.
0066
1 Q. I have dealt with Clinical Directors. I am going to
2 shift the ground a little and ask you about the medical
3 directorate role, and in particular, if we can have
4 a look, please, at UBHT 98/367. We had better go back
5 two pages so we can see what the document is. "Hospital
6 Medical Committee, 20th December 1989".
7 A. I see I was there.
8 Q. Yes. All the documents I have referred you to are
9 either documents of meetings where you have been present
10 or they have been copied to you.
11 A. Thank you.
12 Q. Can we go two pages further on.
13 This is obviously looking forward to the
14 establishment of a Trust, because this is 1989 and the
15 Trusts did not come into operation until April 1991.
16 Here is Mr Boardman discussing the potential roles. The
17 second paragraph "discussed the proposal to set up
18 a structure of Clinical Directors within the authority
19 and their position relationship with the General Manager
20 and the Medical Director."
21 He deals with the two potential structures, so we
22 see what was on the table at that stage.
23 I draw attention to that because this is plainly
24 a formative document.
25 In the first paragraph:
0067
1 "The bill [the parliamentary bill, I think]
2 allowed for five executive directors who would be
3 appointed by the Chief Executive and the Chairman but
4 four of them had to be from nursing, medical, finance
5 and management, leaving only one director who could be
6 appointed without a specific function. He [Mr Boardman]
7 noted that the Chairman of the HMC might not be
8 acceptable to the Trust Chairman and the Chief Executive
9 as the Medical Director."
10 A. I can see why.
11 Q. Tell me why.
12 A. As Hugh Ross said in his evidence to you, the perception
13 of the Chairman of the HMC is that he is the Secretary
14 of the shop stewards, whereas the Medical Director's
15 role is as part of the management team. I think these
16 are complementary roles, and having filled both of them,
17 I think I am comfortable with that. I think that the
18 consultants on the staff of the hospital are comfortable
19 with it too.
20 Q. That is comfortable with combination?
21 A. Yes. I should actually say that in the event, from the
22 day that the Trust Board started the Chairman of the
23 Hospital Medical Committee has sat in the Trust Board;
24 in the strictest terms he may not have been a voting
25 member, but he is always invited and when he is able to
0068
1 be present he is invariably present.
2 Q. Can we go down the page, the same page? What you say in
3 this particular paragraph, beginning:
4 "In answer to Dr Wilkins, the Chairman said that
5 the division of HMC into two, corresponding with the
6 provider units, had not been perceived as wise. He did
7 not want to see the consultant staff divided into
8 pockets whose only relationship with each other was
9 adversarial. Mr Dean Hart emphasised that the more the
10 Chairman could speak with the coherence and confidence
11 of the widest support the stronger would be his
12 position. Mr Baird felt that there was a need for
13 representation from HMC on the new board, but Dr Jordan
14 agreed with him that the Chairman of the HMC in his
15 position would have dual and conflicting roles."
16 So your view at this time was that although the
17 Chairman of the HMC, the shop steward's committee,
18 should be on the Board, nonetheless there would be
19 a potential conflict?
20 A. The way it works is that the Board seeks the advice of
21 the Medical Director on professional issues. In my time
22 on the Trust Board, the Chairman of the HMC seldom said
23 much. The Medical Director reports to the Trust Board.
24 However, the presence of the Chairman of the Medical
25 Committee on the Board is extremely helpful because at
0069
1 the monthly meetings of the Medical Committee which
2 occur a few days after the Trust Board meetings, the
3 Chairman of the Medical Committee can lead the
4 consultant body in a way which is informed by the
5 thinking of the Trust Board at which he has been
6 present.
7 Q. But I think what this minute is looking at is the
8 potential combination of the two: the Chairman of the
9 HMC and the Medical Director?
10 A. Maybe we did talk about that at the time and I think we
11 rightly concluded that a separation of powers was
12 desirable and that that is what happened in the event:
13 that there was -- I think, as I recall it, Christopher
14 Dean Hart was the only person, or maybe Mr Wisheart
15 too -- certainly in the early days there were one or two
16 people who fulfilled both roles.
17 Q. But you used the expression "rightly regarded" there as
18 having to be a separation of roles?
19 A. Yes, I think so.
20 Q. So your view was that there should be separation of
21 roles, even though both the persons plainly should be
22 heard at Board level?
23 A. Yes. I think so. I think the hospital Medical
24 Committee is a very useful sounding board, because the
25 consultants have sometimes great concerns about
0070
1 a certain direction in which the Trust appears to be
2 moving, and there needs to be a Chairman who is fully
3 informed about what is happening but who is seen as
4 sympathetic to the view of the consultants, whereas the
5 Medical Director is regarded as being in the management
6 "camp" if I can use that term, and I fulfilled that
7 role comfortably for a couple of years. In fact you can
8 move from one to the other. You can be the
9 representative of the consultants and then you can
10 retain that credibility, as I did, for a couple of
11 years, I hope, as Medical Director.
12 Q. But what you are saying is you should not do both at the
13 same time?
14 A. I think it can be slightly schizophrenic.
15 Q. Are you saying it then from the point of view of the
16 individual himself?
17 A. Yes. I think it is difficult to look two ways at once.
18 Q. I accept it as a point.
19 A. I do understand some of my colleagues would not agree
20 with that.
21 Q. What about the position of the consultants generally,
22 hospital generally, management generally? Is it
23 desirable in those interests there should be one person
24 combining both roles?
25 A. It is a large organisation. I think there is room for
0071
1 both. Certainly my feeling now, I cannot remember what
2 I felt at the time, but I certainly feel very
3 comfortable with the arrangement we have that evolved
4 after three or four years.
5 Q. Can I put the question another way? The position
6 evolved as you say from there being separate persons
7 being heard or listening at Board level, one being the
8 Chairman of the HMC, one being the Medical Director?
9 A. Yes.
10 Q. What I am asking is, why is that more desirable in terms
11 of the operation of the Trust than one person combining
12 both?
13 A. I think the reason is that if you take any other
14 organisation, a firm of solicitors, accountants,
15 architects or whatever, they have a flat management
16 structure at partner level, they have a series of
17 individuals who are responsible for what they do, and
18 amongst them one pops up to be the managing partner for
19 a bit or the head of chambers or the senior solicitor or
20 whatever, and then they pop back down again, and that is
21 the nature of the Hospital Medical Committee. It is
22 a committee of equals, of whom their Chairman is one of
23 equals, whereas the role of the Trust Board and those
24 who are directors on the Trust Board is one which
25 carries responsibility for the whole organisation, and
0072
1 I do not think that is quite so equal; it is more of
2 a pyramidal arrangement.
3 Q. Moving to a different issue, you, when you became the
4 Medical Director, had what, four sessions a week?
5 A. Yes.
6 Q. For that job?
7 A. Yes.
8 Q. You tell us in the course of your statement a number of
9 the duties that that post involved.
10 A. Yes.
11 Q. Consultant appointments and so on.
12 A. Yes.
13 Q. And a very large number of regular meetings?
14 A. Yes.
15 Q. It may sound a silly question, but did you need all of
16 the four sessions?
17 A. Yes. One reason I stopped doing it was that I felt
18 I could not do both. I took it on to steady the ship
19 because at the time that I was asked to take it on, it
20 was a very upsetting time for all of us in the Trust,
21 and I felt that it was the right thing to do. I did it
22 for two and a half years and I tried to build up the
23 role and to broaden the base of medical involvement in
24 managing the Trust by the Associate Medical Directors
25 and the Chairman of the committee of junior staffing to
0073
1 provide me with expert advice in these Trust-wide areas.
2 I got a bit of help from the juniors in the
3 clinical work, but I did not really feel comfortable
4 with it. I felt that I was being pulled in either one
5 direction or the other, and I decided to relinquish it.
6 Having stopped doing it for a couple of months, I am
7 really quite glad.
8 Q. Do you have rather more time now for your own things?
9 A. Yes. And my wife sees a bit more of me.
10 Q. So, really, the four sessions you were allowed was not
11 enough?
12 A. No.
13 Q. How many would have been, roughly?
14 A. Nicholas Bishop who has taken over from me has quite
15 a neat arrangement, he has seven sessions. But whether
16 he can retain clinical credibility -- he is a man of 47
17 or 48, and an experienced radiologist. Whether he can
18 retain clinical credibility for more than a certain
19 length of time is something that only time will tell.
20 Q. So something of that order, is it, that would have been
21 needed to do the job properly without eating into your
22 personal life?
23 A. Yes. A lot of the meetings, the clinical work runs from
24 9 to 5 roughly and a lot of the meetings are either at
25 8 in the morning or over lunchtime or they start at 5.30
0074
1 and go on until 7 or 8.
2 Q. How did Mr Wisheart, your predecessor, manage?
3 A. By working very hard. Over the whole of his time until
4 he retired, you saw his car in the hospital car park
5 probably more than anybody else's. You would ring up
6 his wife and say "Janet, I would like to speak to
7 James": "Oh, you will find him in the hospital". That
8 is where he was.
9 Q. Would it be fair or unfair to say that in consequence
10 of fulfilling that role, he was probably overworking?
11 A. I do not know. You would have to ask him.
12 Q. I am asking for your view, because you did the job after
13 him.
14 A. Well, I think in the end he found himself in an
15 impossible position.
16 Q. And the demands of the job, you can only speak I think
17 directly from the time you took over?
18 A. Yes.
19 Q. To what extent did it seem to you that the demands of
20 the Trust when you took over were greater or for that
21 matter less than the demands of the Trust upon a Medical
22 Director at the time that Mr Wisheart began that role?
23 A. It is a huge agenda. You have to pick the big issues to
24 deal with and you have to delegate the less big issues.
25 I mean, last year we had 250 Health Service circulars
0075
1 came down. The government was even sending them down
2 between Christmas and New Year. That has never happened
3 before. So you have to filter a lot and sift a lot and
4 it is just -- there is a lot to be done.
5 Q. Part of the importance of management structures for the
6 purposes of the Inquiry is to understand how they did
7 and how they might have responded to complaints or
8 concerns.
9 A. Yes.
10 Q. Can I ask you to have a look, please, at 98/310? Just
11 so we know what we are looking at, can we go back two
12 pages, please? Hospital Medical Committee of 21st
13 February 1990.
14 You were there, as we see. Can we go back to
15 310? This is Mr Johnson talking about complaints
16 received, in general terms.
17 A. This is Mr Johnson of Osborne Clarke, the solicitor?
18 Q. I understand, yes.
19 He describes the first point of contact at the top
20 of the page, his and Mr Gray's function to alleviate
21 worries of consultants when a complaint or complaints
22 were received in the context, I suspect, of medical
23 claims?
24 A. Sure.
25 Q. "Need close co-operation with medical staff in assessing
0076
1 quickly the information which had to be collated in
2 order to produce a sound response. An early,
3 constructive response to a complaint often reduced the
4 chances of that complaint becoming a claim."
5 Tell me, the sense behind that idea, is that
6 a sense which you share from your clinical experience?
7 A. Yes. Just to put it in context, we have, as I recall,
8 about 500 written complaints a year come into the
9 Trust. In terms of medico-legal claims, there are about
10 150 new claims each year which usually the claims come
11 later; they start on average three years after the
12 episode and they usually last for about three years, so
13 there are about 400 or 500 claims on the go and about
14 a similar number of complaints.
15 The written complaints all go into the Chief
16 Executive's office and a holding letter is sent out
17 within 48 hours and the letter is sent to the General
18 Manager of the directorate concerned, who is asked to
19 investigate the complaint and prepare a draft letter of
20 reply for the Chief Executive to sign.
21 The General Manager distributes the letter of
22 complaint to the relevant people. For example, if
23 a patient has complained that there was a deficiency in
24 his or her care and the ward was dirty, then the
25 letter will go to the Ward Sister and also to the
0077
1 consultant concerned.
2 They will help to prepare a response which the
3 General Manager puts into the form of a letter and that
4 letter is returned to the Chief Executive for signature.
5 Q. You deal more specifically with complaints generally at
6 page 16 of your statement, paragraph 60.
7 A. Yes.
8 Q. You talk there about your belief about the increasing
9 number of complaints and say that "complaints will be
10 sent to the General Manager to investigate who would
11 then seek comments from the relevant people and draft
12 a reply."
13 Do I take it that is complaints other than
14 clinical care?
15 A. No.
16 Q. That includes clinical care?
17 A. Yes.
18 Q. So the system was for the General Manager to do the
19 investigation?
20 A. Yes. He or she would, as I say, they would get the case
21 notes and they would see who knew most about that
22 particular episode of care, and the people would deal
23 with it. I mean, I have done it myself. Of course,
24 there are things that you can do to try and nip these
25 things in the bud. If somebody is unhappy, it is often
0078
1 a good thing to ask them to come and see you if they
2 wish, to explain why they are unhappy and to give them
3 an early appointment to allow them to explain what it is
4 that concerns them. Sometimes that helps to resolve
5 a complaint.
6 Q. Page 17 of your statement. You dealt with the General
7 Manager route. You deal in paragraph 62 with the
8 possibility of complaints about doctors' performance
9 possibly being raised with Dr Roylance or the Director
10 of Public Health, or with one of the "three wise men".
11 Then, paragraph 63, you say there were informal
12 routes to raise concern.
13 Then the next sentence. You concede that it may
14 have been difficult for a member of staff to know to
15 whom to turn and how to express their concerns for fear
16 of any consequences.
17 So what you are addressing here are what one might
18 call "internal complaints", concerns about other
19 people's practice. You are nodding. I have to say that
20 because of the transcript.
21 A. Yes, I am sorry.
22 Q. What informal routes did you have in mind in
23 paragraph 63?
24 A. Usually if somebody was unhappy, they would talk to
25 somebody more senior than themselves. If the person who
0079
1 was unhappy was a nurse they would talk to a more senior
2 nurse. If the person who was unhappy was a doctor of
3 some sort, they would talk to a more senior doctor,
4 usually in their own specialty. That is the sort of
5 informal route.
6 I think it would be shortcircuiting the normal
7 arrangements for somebody, if they were unhappy about
8 something, to go straight to a member of the Trust
9 Board -- well, or the predecessor bodies of the Trust
10 Board.
11 Q. Because what you have in mind, I suspect, is that on
12 the whole people are working, although it is a huge
13 Trust, in very small groups?
14 A. Yes.
15 Q. And because it is a small group they know each other?
16 A. Yes.
17 Q. And because they know each other they will talk to
18 each other, because otherwise they would not work there?
19 A. Yes.
20 Q. So you have small social units within a large Trust?
21 A. I would not say "social". I would say they are linked
22 by the clinical bonds that bind them.
23 Q. It is my loose use of language, I am sorry. So there
24 are people they know with whom they are in regular
25 contact and whom they get on all right with, with whom
0080
1 they can raise concerns?
2 A. Yes.
3 Q. So they do?
4 A. Yes.
5 Q. That is what you have in mind?
6 A. Yes. I mean, particularly newly appointed consultants,
7 people often are dissatisfied with aspects of their
8 programme or some aspect of their professional life, and
9 as a senior person, your role is often one of
10 reassurance and, you know, it is the old story that you
11 have to have the courage to change what can be changed,
12 to have the fortitude to live with what you cannot
13 change and the wisdom to know which is which. They may
14 not be happy with their programme, they may not like
15 somebody they work with, but they are new on the staff
16 and you just try and support them as best you can if you
17 are a more senior person.
18 Q. The informal routes that we have described thus far
19 should not, unless somebody is a very square peg in
20 a very round hole, give rise to fears for that
21 individual talking out. So I take it that was not what
22 you had in mind when you were talking in paragraph 63 of
23 the difficulties for members of staff knowing to whom to
24 turn and how to express their concerns?
25 A. Well, I think in the particular circumstances that we
0081
1 are here about, I think some of the people have said
2 that. I know that that is true in the case of
3 paediatric cardiac surgery.
4 Q. So tell me, because you were there and you can tell us
5 from the way you saw it at the time, that is what
6 I want.
7 A. Yes.
8 Q. I do not want something which you only have thought by
9 hindsight. If I were to put you back into your shoes in
10 1992/93, let us suppose, when you know nothing, you tell
11 us, of the furore which is later to break about cardiac
12 services, that is the position you are in, 1992/93.
13 A. Go on.
14 Q. Am I right, you did know nothing at that stage, did you,
15 or did you know something of what was about to break?
16 A. Well, as I have indicated perhaps tacitly, there is
17 a lot of gossip goes on around the place and I knew that
18 there were expressions of dissatisfaction.
19 Q. So can I take it back then earlier, to 1990?
20 A. Well, cardiac surgery -- I am talking mainly about adult
21 cardiac surgery -- has always been a highly risky
22 business. Nowadays it is much more routine and there
23 are very good mortalities, 1 per cent, 2 per cent are
24 now quoted, but when I was a student and when I was
25 a young surgeon in training, it was a pretty bruising
0082
1 place to be. There was a lot of living and dying going
2 on in the cardiac departments. In the 1970s and 1980s
3 the results got better. But you know, there were always
4 people who felt that others could have done better than
5 they did.
6 Q. I am sorry, it has rather taken me away from the line
7 I was pursuing. Could I just follow that answer up for
8 a moment? What I think you are saying is that there
9 were, throughout, concerns which some people had about
10 cardiac surgery?
11 A. Sure, yes.
12 Q. And throughout the time you were at Bristol, you were
13 aware that some people had such concerns?
14 A. Yes.
15 Q. Those concerns were expressed informally to you, amongst
16 others?
17 A. Yes.
18 Q. What sort of concerns were they? About the quality of
19 the surgery, or what?
20 A. Nobody likes a bad outcome, and as I have said earlier,
21 when an intervention and a bad outcome happen at the
22 same time, everybody is upset. Everybody likes the
23 cases to go well. For example, in my work I deal with
24 things called ruptured aortic aneurysms, and they come
25 in and they are in bad shape and their mortality is
0083
1 about 40 or 50 per cent. Sometimes you are in there and
2 you are trying to fix the unfixable and the patient dies
3 in front of your eyes and you see the ECG tracing go
4 flat. That is bad. The whole team feels as bad. You
5 feel a sense of self reproachment. You think, "Could
6 I have done it better? Is there any way we could have
7 saved this patient?"
8 I feel it in what I do and I think it is worse in
9 cardiac. I think it is a tough area. People who
10 criticise it who do not do it ought to think fairly
11 carefully before they criticise it in the way that
12 people sometimes do.
13 Q. What you were saying five or six minutes ago is that
14 despite that, some people will say to themselves,
15 "I could have done this better"?
16 A. No, they would never say that, because then they would
17 be surgeons, if they were saying that. They are what
18 you might call the "supporting ranks". There is the
19 team, the guy taking the risks and doing the work, but
20 he has to retain the loyalty and support of the people
21 around him. That was not always there.
22 Q. So the concerns that were expressed, the concerns that
23 you heard of were concerns from those around the
24 surgeon?
25 A. Sure.
0084
1 Q. Who were unhappy --
2 A. Sure.
3 Q. -- at the devastating outcomes, as they always are, if
4 there is a death, in individual cases?
5 A. Yes.
6 Q. And can I come back from your description of that, which
7 I chased you down a side alley on. What I was asking
8 you about and what led to this was the way in which you
9 put, at paragraph 63, that it may have been difficult
10 for a member of staff to know to whom to turn and how to
11 express their concerns for fear of any consequences.
12 A. I mean, this is an expression that has emerged in the
13 course of this business: that the whistle-blowers, and
14 whistle-blowers wherever they are, have always feared
15 the impact upon them of their whistle-blowing, because
16 it is often adverse. That is the dilemma that the
17 whistle-blower faces.
18 Q. If one were to put oneself in the shoes of somebody with
19 concerns about the clinical performance of a senior
20 surgeon back in 1990, let us suppose, the system
21 officially would or would not support the expression of
22 concern at that time, as you see it?
23 A. It is difficult for me to answer that, because until
24 the events which led up to the GMC Inquiry, I had not
25 been personally involved in such problems of
0085
1 competence. I had heard about them elsewhere -- I am
2 sorry to repeat myself, but if the surgeon is involved
3 in a facet of surgery in which the bad outcome is
4 somewhat remote from the intervention, I mean, we have
5 all seen things that we have not liked, you know, some
6 people may take several weeks to die when something bad
7 has happened to them at an operation and by the time
8 they die, all the people who were present at the
9 original operation have become dispersed so the link is
10 lost.
11 Q. I think what I am asking you is this: in, take 1990, so
12 far as you can think yourself back to then, was the
13 official position of the Health Authority, as it was
14 then, that people should inform on clinical incompetence
15 which they thought they perceived, or not?
16 A. I am sure people would express their concerns, because
17 I think people are always prepared to express them --
18 Q. It is not asking what people would do, it is asking what
19 the position of management was. Was the management
20 saying "Do come forward, let us have your concerns", or
21 was it saying "We do not want to know about that really"
22 because, for instance, it may interfere with the
23 confidence people have in doctors, or whatever it might
24 be?
25 A. I think that is a question for Dr Roylance, because
0086
1 he was the Chief Executive around there.
2 Q. I think it is a question which could be addressed to
3 anyone working in the Trust at the time.
4 A. But if you think of the sanction, let us say you
5 consider the case of a surgeon whose competence is
6 questioned and the sanction. What is the sanction? The
7 sanction is either the surgeon stops doing whatever he
8 does that is bad or he stops being a surgeon. I do not
9 remember either of these things happening.
10 Q. You told us before the last break that there was not
11 actually an awful lot that was or could be done as it
12 happens in terms of competence so far as doctors were
13 concerned, it did not occur much that surgeons changed
14 their roles or lost their jobs for competence reasons,
15 so -- again, this is a view floated for your comment --
16 there may have been a view by anyone who wished to
17 express a concern, "Well, what is the point?"
18 A. No, that would imply a less than open culture, and I am
19 not aware that the culture that you describe existed in
20 the UBHT at that time.
21 Q. So did management actively encourage the expression of
22 concerns, or not, as you saw it?
23 A. I think management was pretty reactive. I do not think
24 it had a proactive view on it. I think if you had asked
25 the senior people at the time, I think they would have
0087
1 insisted that their door was open and if people had
2 concerns, all they had to do was come and express them.
3 I think that is the view that if we wound the tape back,
4 that is what they would have said.
5 Q. So hence your "reactive not proactive"?
6 A. Yes.
7 Q. So far as the individual making or wanting to express
8 the concern, what consequences would that individual
9 have been concerned about?
10 A. I guess they would be concerned about their standing,
11 their professional reputation within the hospital and
12 their standing within the institution. I think nobody
13 would like to be branded as somebody who was outside the
14 group, if you like.
15 Q. So in essence what you are describing here in
16 paragraph 63 is, is it, that in order to express the
17 concern, you have, as people would have seen it, to put
18 yourself outside the group, or outside the club?
19 A. Yes.
20 Q. So you are effectively accepting being blackballed?
21 A. Yes. I would think, yes.
22 Q. Why do you say it may have been difficult for a member
23 of staff to know to whom to turn?
24 A. In the particular instances of the case, the two most
25 senior doctors in the Trust were the Medical Director
0088
1 and the Chief Executive, and if they were the people who
2 were subsequently censured by the GMC as having not
3 behaved properly, then if you had concerns and you had
4 been to them and they had not listened, then I would
5 fear for the consequences.
6 Q. They might say, what about the Royal Colleges? What
7 about the BMA?
8 A. Yes, but as the Inquiry will have heard, they are acting
9 in another arena. I mean, I think one thing that this
10 affair has shown to me is that we need to examine some
11 of our institutions. I mean, I was in America recently
12 and the State licensing boards have a model which is
13 quite interesting, particularly in Massachusetts.
14 I think there may be lessons that we can learn there
15 about licensing and regulation. I think it is going to
16 lie somewhere between the local employer and some sort
17 of regulator body, possibly the GMC.
18 MR LANGSTAFF: Mr Baird, I have again gone on a little bit
19 past our teatime. Perhaps this would be a time for
20 a break before our final push towards 5 o'clock?
21 THE CHAIRMAN: Yes. Shall we say 10 past 4, I am looking to
22 the stenographers whose care and concern I have at
23 heart. We will say a quarter past 4.
24 (4.00 pm)
25 (A short break)
0089
1 (4.15 pm)
2 MR LANGSTAFF: What I want to ask you about next focuses on
3 page 9 of your statement.
4 Having described your role in paragraph 38 as
5 supporting the General Managers -- we have dealt with
6 that already -- you go on, in paragraph 39, to talk
7 about the simplified way in which accounting was
8 initially done. You say halfway down the page in
9 paragraph 39:
10 "Contract money for operations was not given
11 to surgery to share out to cover support services,
12 e.g. anaesthesia" and that came from a different source.
13 At paragraph 40, and this is what I want to focus
14 on, you say "consultants continued to compete for
15 funding for their areas of work."
16 I want to understand how that happened, given that
17 there were providers and purchasers whilst you were
18 Clinical Director, so that there was a service providing
19 so many operations at X pounds per operation, which was
20 going to be paid for, for those operations.
21 Where did the competition for funding come from as
22 between consultants?
23 A. I guess I would have been better to say that it is
24 between consultant groups in particular clinical areas,
25 so, for example, let me take an example of trauma. We
0090
1 deal with in-patient trauma and the Health Authority
2 provides us with a certain amount of money to mend these
3 broken bones, if you like. The Health Authority in
4 a given year, will try to contain the costs of the
5 trauma service by keeping the costs at the level they
6 were the previous year, whereas we may have pressures on
7 the costs like new techniques and new bits of kit and so
8 on that are expensive and we would try to persuade the
9 purchasers that these developments should be properly
10 funded, and the purchasers will show a natural
11 reluctance to accommodate this.
12 In each area, where it is trauma or cardiac
13 surgery or vascular surgery or breast surgery, there are
14 developments coming along all the time, all of which
15 cost a great deal of money for which there is no money
16 available in the purchaser's budget to pay.
17 So that is the competition that I am trying to
18 describe.
19 Q. So where does the money come from to fund such
20 development?
21 A. What usually happens is that you try and make other
22 aspects of care cheaper to pay for the new development.
23 What you cannot do is to not have the new development,
24 because in the end you have to catch up later and it is
25 much more expensive.
0091
1 So when something new comes on the scene, you have
2 to stop doing something that was costing you money
3 before in order to find the money for the new
4 development. You might send a patient home quicker, you
5 might squeeze the size of Intensive Care Unit which is
6 very expensive to run. You need all the tricks of the
7 trade to try and save money in the system to allow you
8 to embrace the development which your professional
9 aspirations lead you to demand.
10 Q. So the idea is from the purchaser's point of view the
11 purchaser pays no more, by and large, but out of the
12 money that they pay, you take a reduced sum for the
13 operations and use the balance to fund the development.
14 Have I got it about right?
15 A. Something along these lines, yes. Maybe not a reduced
16 sum for the operations, but a reduced sum for the
17 episode of hospital care in some way or another.
18 Q. By shortening the stay, or however?
19 A. Yes.
20 Q. You say that winners in what happened included complex
21 low volume work such as cardiac surgery, which suggests
22 that the cardiac surgeons were able to get more funding
23 in the battle that you have been describing?
24 A. Yes. Cardiac surgery, bone marrow transplant, renal
25 dialysis, these are things in Bristol which are
0092
1 programmed for growth. The growth in cardiac surgery
2 has grown from 400 cases a year to 1500 in the course of
3 15 years and that is a system trying to grow organically
4 as fast as the purchasers can make it grow. You cannot
5 grow a service too quickly because there are complex
6 issues in the growth of the service.
7 Q. Whilst cardiac surgery was part and parcel of the
8 Directorate of Surgery, the pattern will be this: that
9 the income which the contract has brought in was the
10 income of the directorate, for the directorate to
11 allocate to spend?
12 A. No, the income from the contracts came to the Trust
13 headquarters, where a fairly substantial top-slice was
14 removed from it, and then it went to the directorate
15 concerned or to the associate directorate concerned,
16 earmarked for activities of that associate directorate.
17 Q. Can I ask you to look at UBHT 181/350? It is a memo
18 from you dated 27th May 1992.
19 You deal with the cardiac surgery in the top large
20 paragraph:
21 "Cardiac surgery is now expected to need all its
22 budget to provide the agreed increase in its contracted
23 workload. This has knock-on effects on the overall
24 directorate budget because in 1991/92 the underspend on
25 cardiac surgery ... was balancing overspends in other
0093
1 specialties."
2 If I were to put that more simply, would it be
3 that the money which cardiac surgery brings in is
4 subsidising other specialties within the Directorate of
5 Surgery?
6 A. Yes. That is of course not allowed at all, but it was
7 happening.
8 Q. That is what you were saying and that is what was
9 happening?
10 A. Yes.
11 Q. You identify, at the bottom of the page:
12 "If no action is taken, the approximate end of
13 year position is as below ..."
14 You see œ139,000 cardiac underspend loss to the
15 directorate.
16 A. Yes.
17 Q. You say that the implications for each specialty are set
18 out below. Let us turn over. Cardiac surgery,
19 estimated overspend, is nought.
20 What was actually happening, whether it should
21 have happened or not, was that cardiac surgery was
22 getting in money which was not being spent on cardiac
23 surgery?
24 A. Yes. They were expanding as quickly as they could,
25 and if you want to expand the service, you have to allow
0094
1 it to settle in a generous financial environment. Then
2 you rely on the individual managers and you work out
3 a way of increasing the number of operations that you
4 are going to do. There are various limiting factors.
5 You might have a shortage of beds, Intensive Care Unit
6 beds, theatre time, surgeons or anaesthetists. There
7 are various rate limiting factors. I am sure they were
8 growing as quickly as they could, but they did not spend
9 all the money that was being provided to them. So the
10 Director of Finance allowed the cardiac surgical
11 associate directorate to operate in a more generous
12 financial framework than he allowed the rest of us.
13 Q. Can we have a look at 181/353? Again, it is a memo,
14 this time from your General Manager with a copy to you,
15 17th September 1992, so four months further on.
16 Let us scroll down.
17 "Projected overspend". We see cardiac surgery,
18 minus 43, so again, cardiac surgery is making money
19 which is being spent on the other disciplines within the
20 Directorate of Surgery. That is the position, is it
21 not?
22 A. Well, you have had Mr Nix. An accountant will tell you
23 what you pay him to tell you, but basically, what would
24 happen is that I suspect the top-slice for the cardiac
25 surgical income was less than the top-slice for other
0095
1 surgical incomes, because we operated under our much
2 tighter financial regimen than the cardiac people did.
3 Q. If we go to page 20 of your statement, paragraph 71, the
4 very last sentence in your statement. You are talking
5 about the split site and the problems it gave. You say:
6 "In neither cardiac nor trauma could we deliver
7 separate medical and support staffing for adults and
8 children."
9 The "could we deliver": presumably that is on
10 grounds of cost, is it?
11 A. Well, in the event, cardiac did go up (the hill to the childrens
12 hospital) and it required a big investment to enable that to happen.
13 Trauma has never been able to go up (the hill), but as you will know, a new
14 Children's Hospital is currently under construction, and
15 in children with broken bones, the treatment for them
16 will be much more -- we will not have to make that huge
17 investment in order to equalise the care of children.
18 But, yes, it was -- yes.
19 Q. When you say "Yes", you say essentially there are
20 financial reasons which were restricting some of the
21 things that could be done?
22 A. Of course, yes.
23 Q. So far as if one were to isolate, if it were right to
24 isolate, cardiac surgery, one would see, as you have
25 told us, that it was bringing in more money than it was
0096
1 spending?
2 A. Yes.
3 Q. It was subsidising other aspects of the directorate of
4 surgery.
5 One of the arguments, as I understand it -- tell
6 me if I am wrong -- in favour of the Directorate of
7 Cardiac Services developing was that cardiac service
8 would then have control of its own budget?
9 A. Yes.
10 Q. That implied to the cardiac surgeon, did it, that the
11 cardiac surgeons would then be able to spend the money
12 they were creating through the cardiac surgery contracts
13 upon cardiac surgery?
14 A. Yes.
15 Q. Is it one of the ironies of life that cardiac services
16 included cardiology? You are nodding.
17 A. Yes.
18 Q. Did cardiology in fact require more money to be spent on
19 it than it was producing?
20 A. Yes.
21 Q. Because of expensive procedures?
22 A. Yes.
23 Q. So a move undertaken to allow cardiac surgery the
24 benefit of the finance it was creating in fact did not
25 achieve that result necessarily?
0097
1 A. Yes. That is true. But I would not like to leave the
2 impression that the sole motive for creating the
3 Directorate of Cardiac Services was financial. You want
4 to create a directorate structure which allows natural
5 clustering of people together and the development of
6 cardiac services had reached sufficient of a critical
7 mass for it to survive as an independent directorate,
8 I think. I put that argument ahead of the financial
9 one. I think the financial one certainly ought to have
10 followed it; I do not think it should have led it.
11 Q. I think, following from your comment -- we are beginning
12 to run short of time this afternoon, but if I can just
13 mention on the Internet, for those who want to follow
14 that up, the paper which describes, so far as we can
15 see, the origin of the development of the cardiac
16 services directorate we will find at UBHT 38/240 and the
17 pages that follow. I mention that for those who are
18 interested, so they can follow that. The Panel will,
19 I know.
20 You say in respect of the time that you were in
21 charge of the budget, albeit nominally, not being
22 a budget holder yourself, at page 10 in your statement,
23 that funding for surgery was ring-fenced and the size of
24 its ITU was protected.
25 Tell me how it was that funding for cardiac
0098
1 surgery was ring-fenced? What do you have in mind
2 there?
3 A. I have seen Mr Wisheart's comments on my statement and
4 he reminds us that the term "ring-fenced" had
5 a particular connotation and was associated with
6 supra-regional specialties.
7 Q. I wondered if that was what you meant?
8 A. I meant it more in an imprecise functional sense rather
9 than the sense in which the Health Service bureaucracy
10 used it. I meant it simply in the way that I have
11 already explained, that they were not subject to the
12 same financial constraints as the rest of us.
13 Q. So "protected" rather than "ring-fenced"?
14 A. Yes, "protected" would be a better word.
15 Q. Protected by decision and practice rather than by any
16 reason of obligation?
17 A. Definitely, yes.
18 Q. Otherwise there would be a conflict between what you
19 say at paragraph 42 about funding being ringfenced,
20 a static, fixed amount, and a couple of paragraphs
21 earlier where you say cardiac was one of the winners in
22 the battle for funds?
23 A. If I can take the other half of that sentence, and the
24 size of the ITU was protected, ITUs are extremely
25 expensive assets for a hospital and the general ITU that
0099
1 the rest of us used is sort of first come, first
2 served. My patient tomorrow may be cancelled if there
3 is not an ITU bed available because of pressure on it
4 from all over the hospital except for cardiac. Cardiac
5 has its own ITU and they can regulate supply and demand
6 into their ITU independently. They do not have to play
7 along with unexpected demands from other parts of the
8 hospital like the rest of us do.
9 Q. There are a number of references which I was going to
10 ask you about, about the beds in the ITU. Perhaps if
11 I can just track it generally and see if you recognise
12 what I describe and whether it is accurate or not, and
13 if necessary, we can look at some documents.
14 So far as the ITU was concerned, in 1990 the
15 surgical ITU had, as I understand it, 7 beds and there
16 was a proposal to increase to 10.
17 A. Yes.
18 Q. Rapidly, by June 1990, that became a proposal to
19 increase it to 12 beds?
20 A. Yes.
21 Q. That was to be provided by May 1991, obviously less beds
22 in the interim while the development took place?
23 A. Yes; well, the whole place was blitzed and the temporary
24 ITU was established a floor above.
25 Q. In January 1991, just a few months before the Trusts
0100
1 began -- perhaps we could have a look at the document,
2 UBHT 200/46. It is 4/9 1(b)(ii):
3 "Because of the lack of funds, the ITU would
4 remain at its present size of seven beds when the
5 ceiling replacement and refurbishment were undertaken."
6 It is those words, "because of the lack of funds."
7 A. Yes, but I suspect -- I mean, the funds were not the
8 capital funds to fund the structural changes in the
9 hospital; the funds were the funds to pay the revenue
10 costs of employing the nurses to staff the beds.
11 Bearing in mind that an ITU -- I do not know what
12 the ITU requires, I have a feeling it is some huge
13 number of nurses, like may be seven nurses for one bed
14 have to be employed, but I would need notice to give you
15 an accurate figure there. In other words, the revenue
16 costs of each ITU bed are very large indeed. We reckon
17 that an ITU bed costs more than œ1,000 per day to the
18 hospital.
19 Q. Inevitably, that minute saying "We are not going to
20 provide or fund the 12 beds, which we were going to
21 provide from May 1991, because we do not have the money
22 to do so", caused a bit of a stir?
23 A. Sure. I mean, we did build the 12 beds. What happened
24 was that we left the size of the ITU at seven and the
25 remaining five beds were used to bring the coronary care
0101
1 unit over from the other side of the hospital where it
2 was rather remote and the two units ended up as they are
3 now in 1999. These five coronary care unit beds are now
4 about to be converted into high dependency unit beds
5 because of the pressure on the ITU, but the difference
6 between a high dependency bed and an intensive care bed
7 is that the number of nurses per bed is less. It is
8 more one nurse between two beds rather than one nurse
9 for one bed. The coronary care units will be
10 reprovided, but it has taken us another eight years to
11 get there.
12 Q. Can we look at 200/23, which takes us to May when the 12
13 beds were originally anticipated. ITU (i):
14 "Funds are available to staff only 5 of the 7
15 available beds. There was a discussion about this very
16 unsatisfactory state of affairs ..."
17 You have, in (ii), the development you were
18 talking about, I think, to relocate the coronary care
19 unit into 5 of the beds, leaving only 7 for general use.
20 Are these beds which would also be used for
21 cardiac patients or not?
22 A. No, they were on the floor above and protected from all
23 of this awfulness.
24 Q. So that there is no misunderstanding, you are, I think,
25 the first person who can tell us with authority, you
0102
1 recollect that there has been a difference of view
2 between two sets of rapporteurs from the specialist, the
3 SAC and the Hospital Recognition Committee as to where,
4 physically, the operating theatres and the ITU were
5 located.
6 Am I right in thinking that the operating theatre
7 was two floors below the ITU used for cardiac services?
8 A. At that time it was. Today they are on the same floor.
9 Q. But then?
10 A. Then they were two floors apart.
11 Q. And access from one to the other by means of a lift?
12 A. Yes.
13 Q. A small lift?
14 A. Yes.
15 Q. And once one got up to the floor where the Intensive
16 Care Unit was, a distance to be pushed along a corridor
17 before one got to the ICU?
18 A. Yes.
19 Q. Thank you for clarifying that. We now have the evidence
20 that we anticipated we might have.
21 So you are saying, none of the funding concerns
22 about the ITU had an impact on cardiac services?
23 A. No. They were entirely separate parts of the
24 institution.
25 Q. Can I have a look, then, at 81/138? It is the top item
0103
1 on the page. Just so you know what this is, can we go
2 back to 133 and we will just identify the document.
3 "Directorate of Surgery Management Board,
4 21st September 1993".
5 A. Thank you.
6 Q. The meeting has been chaired on your behalf.
7 A. Yes.
8 Q. Back then, please, to 138. The top of the page:
9 Mr Dhasmana appears to have identified problems relating
10 to the availability of beds for cardiac patients.
11 A. Well, I suspect he was referring to ordinary ward beds
12 rather than intensive care beds. I am not surprised
13 that anybody in the BRI complains they cannot get their
14 patients in, especially from long distances.
15 I frequently complain of that myself. I guess the point
16 you wish to put to me is that for a subspecialty that
17 I have portrayed to you as having protected assets, they
18 were not completely protected.
19 Q. That is right.
20 A. Sure, but sometimes the hospital becomes full and even
21 the best protection cannot protect you in these
22 circumstances, but subject to that caveat, I stand by
23 what I said to you before.
24 Q. Could I return from looking at the beds to where we
25 began, which was paragraph 42, page 10 of your
0104
1 statement.
2 You talk there in the third sentence of the
3 purchasing Health Authority's policy to minimise the
4 growth of high-tech expensive acute care.
5 Is it not the case that major capital investment
6 was a matter as between the Trust and the Regional
7 Health Authority, the South Western Regional Health
8 Authority, which did not concern the District Health
9 Authority?
10 A. Yes. I think when I talk about the growth of high-tech
11 expensive care, I am talking about the revenue growth of
12 supplying the service. I think you are right, although
13 I think the finance people would know better than me,
14 I think if we were going for a large capital sum, it is
15 to the region that we would go.
16 Q. Dealing with the funding, the regular funding as opposed
17 to the capital, in the last sentence of that
18 paragraph you talk about reluctance to fund the demand
19 in full.
20 What demand did you have in mind?
21 A. The demand as measured by cardiac interventions per
22 100,000 of population.
23 Q. I suppose it would be for the purchaser to identify
24 precisely what the demand was and to ask the provider,
25 the Trust, to fulfil it?
0105
1 A. Yes, but in virtually every area of the purchaser's
2 activity, the purchaser is unable to fund in full the
3 demand because the demand is infinite.
4 Q. Your complaint here about paediatric cardiac surgery
5 and the Health Authority is that the District Health
6 Authority's policy was to provide more care in the
7 community at the expense of care in hospital, is it?
8 A. If you have a certain amount of money, it goes further
9 if you spread it thinly in the community than if you
10 spend it all on a very expensive high-tech hospital.
11 Q. So you are saying that this is not really a criticism of
12 the District Health Authority, they have to balance
13 their own priorities?
14 A. Of course, but this is a fact of life.
15 Q. This is a statement that you were not getting as much
16 money as you might have done because there were these
17 legitimate concerns of the district.
18 A. And as the hospital consultant, I would say that,
19 wouldn't I?
20 Q. Yes, thank you. So far as, if we just go over to the
21 next page, page 11, paragraph 44, you talk about cost
22 pressures and mention items of equipment failure, staff
23 absences and so on. Do I take it there were reserves,
24 contingency funds available?
25 A. Yes, we never knew how much Mr Nix had in his hip
0106
1 pocket. He concealed it very cleverly. If we thought
2 he had more, we would have spent it.
3 Q. Did you have, as a directorate, a contingency reserve
4 or not?
5 A. No, we were not clever enough. The Finance Department
6 never devolved itself, it was always very tightly held
7 at the centre and they always knew what was going on.
8 I am not sure if the rest of us did. Maybe the managers
9 did, but I am not sure if the clinicians really knew
10 where all the money was.
11 Q. At page 14 -- I now want to turn to a different topic --
12 you say, paragraph 55, the bottom of the page:
13 "The professional line of nursing accountability
14 was squeezed by the removal of some of the intermediary
15 layers of nurse managers."
16 Then these words:
17 "It is now evident that the General Managers did
18 not sufficiently take into account the feelings of the
19 nurses, nor the ideal nursing structure, and this led to
20 instances of ill-feeling and low morale."
21 "It is now evident ..."
22 A. Yes. We have a new arrangement with Mrs Maisey's
23 successor in which the line of nursing, professional
24 accountability, has been bolstered, and I think we are
25 better placed now to provide the sort of nurse
0107
1 management arrangements that are perhaps better than
2 they were.
3 Q. The period you are covering in your comment that "it
4 is evident that General Managers did not sufficiently
5 take into account the feelings of the nurses", are you
6 looking at the period immediately before and following
7 the commencement of the Trust, or are you looking
8 further back to when general management and the Health
9 Service itself began?
10 A. That I think has its roots with the Salmon
11 reorganisation.
12 Q. So you are looking back to Salmon and the mid-1980s?
13 A. Yes.
14 Q. To what extent would you take the view that the
15 implementation of general management, without any
16 central guidance for the management of professional
17 clinical activities, after having had those structures
18 from before the setting-up of the NHS, that that may
19 have led to the lowering of morale in the nursing
20 services?
21 A. I think there is also an issue of the nurses adapting to
22 change, and none of us finds it easy to cope with
23 change. I think the nurses were no exceptions to that
24 rule. We had to remind ourselves of the need for good
25 nursing leadership, just like there is a need for good
0108
1 medical leadership.
2 Q. The top of the next page, page 15. You describe how,
3 when Margaret Maisey was the professional leader of the
4 nurses, she was actually perceived primarily as the
5 Director of Operations rather than as professional
6 leader of the nurses.
7 That is my way of expressing what I think you are
8 saying. You are nodding.
9 A. Yes.
10 Q. So to what extent would you say that the nurses were
11 disenfranchised as a result?
12 A. I do not know. I would not say they were
13 disenfranchised. I think she ran the place her way.
14 I think she was a very stalwart supporter of the nurses
15 up the line towards the Chief Nursing Officer for
16 England and the Regional Nursing Officer. I think she
17 was a great defender of the nurses, but within the Trust
18 I think she had her way of dealing with them. They
19 sometimes railed a little against it.
20 Q. Why?
21 A. As anyone does against strong leadership, sometimes.
22 Sometimes organising nurses is like herding cats.
23 Q. You have used three expressions there which I would like
24 just to explore a little bit further. You have talked
25 about strong leadership, people railing against it, and
0109
1 I think there is a sense you are giving that people may
2 not entirely have liked the direction that they had from
3 the Director of Operations, or some people may not have
4 done, and that then you described the impossibility of
5 her task because you have described nurses as the
6 equivalent of a "herd of cats"?
7 A. I think I should withdraw that last remark.
8 Q. You may have seen the stares from one of the nursing
9 members on the Panel, but ...
10 So can you give me a bit more detail as to the
11 strong management or leadership which people may have
12 railed against and your description of Margaret Maisey
13 having her way of dealing with nurses?
14 A. I think any leader does. I think they impose their way
15 of doing things. Margaret had strong opinions and
16 a clear sense of the direction in which she thought that
17 the nursing organisation should go. I do not think
18 I ever sensed any major disagreements on substance;
19 I think, you know, all the nurses would have liked the
20 staffing levels to be better than they were;
21 professional development, I think she did her best.
22 I think there is always more that can be done. The
23 nurses were never afraid to say what they thought about
24 the leadership that Margaret Maisey provided.
25 Q. You say there was no disagreement on substance; was
0110
1 there any disagreement or disaffection about style?
2 A. I think she had quite a vigorous style. I would like to
3 make it clear that I have a great respect for the things
4 that she did in her time at the hospital.
5 Q. I am not asking you about what she did or what she
6 achieved, but the question was directed to your comment
7 about the manner and the style. That is what I was
8 seeking some further elucidation on, and how you saw it.
9 A. Yes.
10 Q. It followed both from the part of your statement where
11 you talk about what I put to you was disenfranchising of
12 nurses for your comment, and slightly tendentious. Does
13 it have any relationship to the "fear of expressing
14 concerns" which you talk about in your statement?
15 A. No, I think she always very faithfully listened.
16 I think if she was in "executive" mode, you knew where
17 she was coming from, but she was sometimes in
18 "contemplative" mode and she then was a good listener.
19 Q. So it depended?
20 A. Yes, of course, as with all of us. Well, some of us.
21 Q. If someone found her in executive mode --
22 A. Then she was saying what she wanted done.
23 Q. Rather than listening?
24 A. But there were other occasions when she was a good
25 listener.
0111
1 Q. How easy would it have been for someone to find her
2 available to them?
3 A. I imagine for a junior nurse it would not be
4 particularly easy to talk to the Director of Operations
5 or the Director of Nursing, although some of them would
6 catch her eye and want to speak to her, but she was
7 well-supported, as I have said before, by experienced
8 nurse managers and she worked well with them and they
9 were loyal to her.
10 Q. You have spoken about the morale of nurses and the
11 approach of the General Managers following Salmon. Did
12 clinical grading and any fuss there may have been over
13 clinical grading following 1988 have any impact upon
14 morale?
15 A. Yes, well, there were winners and losers. Yes. They
16 were considerably upset, I think, some of them, because
17 they had not got the grades they wanted. There were
18 lots of appeals and there was a lot of management time
19 taken up hearing appeals. As I say, there were winners
20 and losers.
21 Q. Was there a difficulty over nurse training?
22 A. My knowledge of this is peripheral, but the nurse
23 training used to be undertaken on site and now nurse
24 training is done in the context of a degree at the
25 University of the West of England.
0112
1 Q. Which means someone has to provide the clinical care
2 which nurses, because they are being trained in the
3 classroom, or at least elsewhere, can no longer provide?
4 A. Yes.
5 Q. That would involve training up nursing auxiliaries,
6 would it?
7 A. I think the term is "health care assistants", nowadays.
8 I was brought up, we survived on student nurses. They
9 were around the place. Then suddenly they are all very
10 clever and they have degrees.
11 Q. So if one is looking at nurses and nursing throughout
12 the period 1984 through to the early 1990s, we have
13 a period where the Salmon developments in the mid-1980s,
14 the introduction of general management, the morale
15 problems that causes is what you are saying, and you are
16 saying --
17 A. There was a thing earlier, Project 2000. That was in
18 on it as well.
19 Q. Clinical grading, then stirs the pot?
20 A. Yes.
21 Q. We then have the consequences for the hospital in
22 managing its beds with nurses in training no longer
23 being available to do the job?
24 A. Yes.
25 Q. Those all in the context of no real increase in finance,
0113
1 so one way or another, you had to manage?
2 A. Yes, I stand to be corrected by nurse experts, but
3 I have the feeling there was some compensation in the
4 form of funds called Project 2000, but I do not think
5 the amount of money that was provided was sufficient to
6 cope with the changes that had to be accommodated.
7 Q. Can I have a look briefly at two documents. One is
8 203/63 and can we go down, please, to the letter from
9 Dr Johnson? This is January 1989. "The Division
10 considered a letter from Dr Johnson stating the Division
11 of Anaesthesia were not prepared to undertake clinical
12 anaesthesia in the absence of trained and qualified
13 support staff".
14 Was there, in 1989, problems with getting
15 anaesthetic cover for operations?
16 A. That letter could be dated this year. I mean --
17 Q. It has been ongoing, has it?
18 A. Yes. I mean -- yes. I mean, probably in a different
19 part of the Trust. We have a problem just now up in the
20 Maternity Hospital with the provision of anaesthetic,
21 expert nurse or expert assistants for anaesthetists
22 doing Caesarean sections. That is actually an issue
23 this year.
24 Q. I am going to ask you, not just yet, but I am going to
25 ask you in a moment to comment upon the extent to which
0114
1 problems generally in the Directorate of Surgery had an
2 impact, or may have had an impact, upon the care
3 provided in the paediatric cardiac fields. Do not
4 answer just yet, because there is one further document
5 I would like you to have a look at before you answer.
6 It is UBHT 83/153.
7 This is a letter addressed to you, or originally
8 addressed to you. It appears someone may have
9 redirected it --
10 A. It was copied to Janardan Dhasmana, as well.
11 Q. It says:
12 "We have agreed your request that two nurses
13 should be seconded from cardiac surgery to the King
14 Edward building from Monday 18th February until
15 31st March to enable general surgery and urology to
16 maintain a minimal service for emergency and urgent
17 patients, recognising the appalling situation in which
18 you and your colleagues find themselves."
19 A. You know why this is happening. The key date is 31st
20 March, the end of the financial year, so we are being
21 squeezed, you know, if you are overspending, the
22 traditional way is you stop employing people, and you do
23 it towards the end of the financial year and this is
24 a managerial way of -- you might call it virement. It
25 is the movement of staff from one area to another, and
0115
1 it helps us. Cardiac can afford it and it helps the
2 Trust to come in on the budget at the end of the
3 financial year. I suspect this is a temporary thing in
4 the last three months of the year.
5 Q. It leads me to ask, it is your statement, page 9, the
6 top paragraph, paragraph 37:
7 "A lot of concern about the hypothetical question,
8 what happens when the money runs out, we will not be
9 able to treat patients. My perception was that the
10 managers would have ensured that this did not happen."
11 The letter we have just looked at is bound to have
12 consequences, is it not, in terms of patients being
13 cared for?
14 A. All that I can say is that the letter that we have just
15 seen is an example of the kind of juggling that goes on
16 in the last three months of the financial year. It
17 could have happened this year. I think in any financial
18 environment this sort of thing happens.
19 Q. What I think I am asking you is, what you say in
20 paragraph 37 could be interpreted as you are saying,
21 "Well, whatever the financial constraints, they did not
22 really have any effect".
23 That is not what you are saying, is it?
24 A. No. No, I mean, the hospital broadly speaking had the
25 same amount of money after it became a Trust as it did
0116
1 before, with a little correction for inflation and so
2 on.
3 The main financial impact of Trust status is that
4 instead of identifying a global sum of money which was
5 the running costs of the hospital, it split that sum up
6 into individual amounts associated with various forms of
7 activity within the hospital. We had to co-ordinate our
8 activities to make sure that we balanced the budget at
9 the end of the year.
10 Q. Let us have a look, shall we, at WIT 159/86. It is
11 a letter we got from a witness about the cardiac
12 catheterisation contract for Southmead. That would have
13 fallen under the Directorate of Medicine in 1993, and
14 then cardiac services later?
15 A. Yes.
16 Q. If we just scroll down, it is the middle paragraph:
17 "I think that one issue thrown up by all this has
18 been that there is a need for us to be carefully
19 auditing our [financial] performance throughout the year
20 so that sudden crisis directives, such as one given from
21 UBHT that we cancel all non-emergency and non
22 long-waiter patients, can be avoided ..."
23 Am I right to understand --
24 A. I wish that we could. In an ideal world, none of these
25 things would happen.
0117
1 Q. This is finance causing non-treatment, at that time?
2 A. No, this is a responsible arm of government trying to
3 balance the books.
4 Q. I do not want to debate the morality or ethics of it,
5 just the consequence and the fact. Is it the fact that
6 whether the decision is right or wrong, a shortage of
7 money has led to a lack of treatment?
8 A. Yes. There were always pressures on the cardiac
9 catheterisation budget. There were always more people
10 that could be investigated than there was the money to
11 do it and they tried to increase the number that were
12 done year on year, but there were often problems like
13 this and we would always try to resolve them.
14 I mean, in recent years there have been what are
15 called "waiting list initiatives" that have been done to
16 try to cope with these obstructions.
17 Q. So although the spirit might have been willing, the
18 pocket was sometimes too weak?
19 A. Yes.
20 Q. Just a couple of other little matters which I wanted to
21 tidy up before I sit down. Can we go to page 19,
22 paragraph 68 of what you tell us?
23 You are describing, I think, a health care culture
24 in the South West. In so far as there would be a health
25 care culture, it would be the South West Regional Health
0118
1 Authority's culture, do I take it?
2 A. Yes.
3 Q. Again, you look here at the question of capital
4 funding. Of course capital funding would have been
5 administered at a regional, departmental level, not at
6 District Health Authority level?
7 A. Yes.
8 Q. You talk about a failure in 1989 to appoint a new
9 paediatric cardiac surgeon.
10 "1989" is wrong, I think, is it not?
11 A. Yes, we discussed this outside this room, and I wrote
12 that in good faith, but I do not have evidence to
13 support it, so I accept, if you tell me it is wrong.
14 Q. Just so that you are satisfied, because I do not want to
15 have your name up for anything which may not be right,
16 can we look at 200/62? This is 1990, as you can see
17 from the minute?
18 A. Yes.
19 Q. In fact, if you go down to the bottom of the page, it
20 talks about the "possibility of a Chair of Cardiac
21 Surgery at the Bristol Royal Infirmary", so it is
22 a possibility at this stage, "... wish to enlist the
23 support of the division in this venture. The Chair will
24 be funded by the British Heart Foundation."
25 It talks about the salaries and the money,
0119
1 a consultant senior lecturer being available following
2 the retirement of Mr Keen.
3 If we go to 200/24 and go down, please, this
4 again, as you can see, is 1991:
5 "As previously agreed, there is to be a Chair ..."
6 One thing which one notices about these minutes is
7 that there is no reference to the holder of the Chair
8 being a paediatric cardiac surgeon?
9 A. I can only tell the Inquiry what my recollection is.
10 I think a lot of these aspirations were informal. The
11 establishment of a Chair in the University is, as
12 members will know, a complex business. There is an
13 Academic Secretary. The Vice Chancellor convenes
14 a Committee of the Council of the University, I believe,
15 and the Dean of the Faculty does a lot of the
16 negotiating. So I think anything that you see in the
17 papers from the hospital is to an extent derivative, and
18 the primary evidence will lie in the university papers.
19 Q. You know, do you, that the applicants for the post
20 included a paediatric cardiac surgeon, at least at one
21 stage?
22 A. Yes.
23 Q. But were not restricted to paediatric cardiac surgeons?
24 A. Yes.
25 Q. Indeed, as you point out, an adult surgeon was
0120
1 eventually appointed, the paediatric candidate having
2 withdrawn?
3 A. My experience of Chairs in clinical specialties is that
4 quite often it is unduly restricting to confine the
5 interest to a narrow subspecialty within the discipline,
6 and you are as much looking for the person as the
7 interest. We all make a great deal of effort to get the
8 right people. We try to accommodate their clinical
9 interests. So I would put it that way round.
10 Q. Mr Baird, I think that is all that I have time to and
11 all that I shall ask you about today. Can I thank you
12 for my part for having answered the questions that I put
13 to you?
14 Perhaps there is one matter I should just ask you
15 to comment on. If you take a look, if you please, at
16 98/310, two matters are dealt with here: the decision or
17 the freedom of consultants to use new procedures and the
18 importance of recording informed consent if and when
19 they do.
20 It is the paragraph which begins:
21 "In answer to Dr Burton, Mr Johnson said that he
22 thought it unlikely that the District Health Authority
23 would attempt to stop procedures being carried out by
24 members of the medical staff because of excessive risk."
25 Just pausing there, is that right as being --
0121
1 A. No, it does not ring true. Just reading it for the
2 first time, it does not ring true to me. Can you remind
3 me of the date of this?
4 Q. Let us go back.
5 A. This is 1990, is it not?
6 Q. January 1990?
7 A. So this is actually -- you see, this is a discussion
8 about what might happen, is it not?
9 Q. It is.
10 A. After Trust status was established; is that right?
11 Q. Yes.
12 A. I think this is a hypothetical discussion and I do not
13 think that is the way things turned out, in the event.
14 We are always doing new things. We only discuss them
15 with the District Health Authority if we want money from
16 them.
17 Q. The next paragraph, then:
18 "Dr Rees questioned the legal aspect of giving
19 consent to treatment and Mr Johnson said that the mere
20 signing of a consent form by a patient mattered little.
21 The important point was the details given to the patient
22 in the way of explanation and if there were any consent
23 difficulties, these should be noted in the case
24 records."
25 A. Well, that is true.
0122
1 Q. That is right, is it not?
2 A. Yes.
3 Q. It fits with what is said in the previous paragraph, the
4 second sentence:
5 "The importance of discussion between
6 practitioners and patients when any high risk procedure
7 was to be undertaken."
8 That is something you endorse, is it not?
9 A. Yes, of course. Yes.
10 Q. And the need for clear note-keeping was of great
11 importance.
12 Going on to the paragraph beginning "Dr Rees...",
13 the third sentence:
14 "Mr Johnson also noted that an individual's
15 clinical judgment in undertaking a new treatment and/or
16 using a drug outside of its product licence was
17 a defensible position and need not be referred to an
18 Ethics or Research Committee."
19 Plainly this is advice which was given at the
20 time. I simply want to ask you for your perspective as
21 a clinician in 1990, using this as a springboard.
22 A. I mean, on the point on the drugs, drugs are quite often
23 licensed in a quite restrictive way, in other words,
24 they receive a product licence for quite a restricted
25 application.
0123
1 Q. I am sorry to cut you short, I do not mean to do so, but
2 if you leave aside the drugs, I would just be interested
3 in your view of what the current view was back in 1990,
4 bearing in mind it is not 1999, it is 1990, as to
5 whether a consultant was, if he wished, entirely free to
6 undertake a new treatment and what restrictions there
7 might be on it, within the Bristol hospitals?
8 A. I think the answer would be the same today as it was
9 then: that what we are able to do for patients is
10 constantly on the move and we cannot stand still and we
11 are always doing new things to people and we are always
12 revising the way that we do things to people.
13 One obvious example is the change from the
14 palliative Senning operation for cyanotic heart disease
15 in infants to the anatomically correct switch
16 operation. That was a change in practice and it was
17 clear you could not go on doing the Senning.
18 Q. What, if any, restriction would there be upon the
19 clinician deciding to undertake a possibly exciting new
20 treatment?
21 A. What you are going to have to do is enlist the support
22 of those on your team, those who worked with you,
23 because if you do not, you cannot do it.
24 Q. So it would be a question of there being lengthy,
25 possibly, discussions with those with whom you worked
0124
1 closely?
2 A. I can think of an issue like this arising about 6 months
3 ago.
4 Q. Squaring the circle where we began this afternoon, would
5 this come up to Clinical Director level?
6 A. It did, and it came up to me. I can think of the
7 precise example. People were anxious about what one of
8 the consultants wanted to do, and we talked it through
9 and having heard the arguments, I felt that the
10 consultant should be supported but that we should be
11 very careful and watch the individual cases.
12 Q. That is coming up to you as Clinical Director?
13 A. As Medical Director. The Clinical Director in the
14 specialty concerned consulted me and I think there had
15 been anxiety on the nursing side as well and the
16 Director of Nursing and I discussed it. I took further
17 advice and I said, "Look, I think we must go with this.
18 We have to see where it goes". I could understand
19 people's anxieties. In the event, it is okay, but it is
20 a worrying time for us all.
21 Q. So in general, that would be the way it should be
22 handled; it should go?
23 A. Yes, well, that is how it has been handled in my
24 experience.
25 Q. To what extent in deciding to support the clinician
0125
1 wishing to undertake the new treatment would a decision
2 be made by the Clinical or Medical Director to keep the
3 procedure under review in the early days?
4 A. It is difficult for the Medical Director to do it
5 because you are one stage removed from it. I think what
6 I tried to do was to give advice to the Clinical
7 Directors, because it was on their patch.
8 Q. So when you authorised -- I say "authorised" -- when you
9 discussed and agreed it should be done, you were
10 expecting the success or failure of the procedure to be
11 monitored?
12 A. Of course.
13 Q. And a report made to you.
14 A. Not in a formal sense. These are informal discussions.
15 Since then, if I can think of the procedure that is in
16 my mind, a few of them, maybe three or four of these
17 things have been done and they have gone okay.
18 Q. Mr Baird, I have trespassed on your time and the
19 stenographer's time more than I meant to. Can I thank
20 you? Is there anything you would like to add that you
21 think that you might have been asked about and would
22 like to volunteer to us, or anything you would like to
23 say by way of clarification or addition to your
24 evidence?
25 A. I have nothing to add, sir, thank you.
0126
1 THE CHAIRMAN: Mr Langstaff would normally now remind you
2 that the Panel may have some questions. As it happens,
3 Professor Jarman has a question.
4 Examined by THE PANEL:
5 PROFESSOR JARMAN: Just one brief question. In paragraph 35
6 of your statement you were talking about Dr Roylance and
7 you referred to "his decision to make us a first-wave
8 Trust". It sounds as though he made the decision
9 himself?
10 A. I should make it clear that the decision that he
11 reported to us was a collective decision of the
12 Executive at the time.
13 PROFESSOR JARMAN: Thank you.
14 THE CHAIRMAN: I have no questions. Mr Miller?
15 MR MILLER: May I keep them brief?
16 RE-EXAMINED by MR MILLER:
17 Q. Mr Baird, that last document you were looking at which
18 is UBHT 98/310?
19 A. Yes, I have it here.
20 THE CHAIRMAN: It is still on the screen.
21 MR MILLER: You may remember that at the beginning of 1990,
22 there was a change, the introduction of Crown indemnity
23 which brought into the Health Authority fold
24 responsibility for medical negligence claims as opposed
25 to the defence organisations.
0127
1 This document here appears to be the Health
2 Authority's solicitor giving advice on various aspects
3 and also advising doctors, because there are doctors
4 there, about maintaining links with the defence
5 organisations rather than simply giving them up on the
6 introduction of Crown indemnity. We do not have the
7 whole of the document here, but was there a discussion
8 about the implications for doctors when the defence
9 organisation stood back and the Health Authorities took
10 over?
11 A. That is certainly the case. I had forgotten that that
12 happened at that particular moment.
13 Q. Going back to the beginning, as Clinical Director for
14 the Directorate of Surgery, Mr Langstaff was asking you
15 about what you saw your responsibility as being. Is the
16 Trust to take it that the effect you had, the
17 responsibility to police the performance or the
18 competence of all the surgeons within that directorate?
19 A. I think "police" is too strong a word. I would have the
20 responsibility of responding to any anxieties that
21 occurred, but I do not think I ever saw it as my role to
22 proactively police it.
23 Q. It is the reaction to complaints or worries, concerns
24 that may be raised.
25 A. That is right.
0128
1 Q. Would it have been possible for you not to have taken at
2 face value what people said and simply pulled notes out
3 and done your own audit on performance?
4 A. Yes, I think that is correct.
5 Q. I catch a smile on Mr Langstaff's face in response to
6 that answer, which I think he expected in the negative
7 rather than the positive. I think that the Panel will
8 know what you are saying. But you had the other
9 elements of the surgical directorate under your wing as
10 well?
11 A. Yes, that is correct.
12 Q. If you just look at your witness statement, paragraph 63
13 on page 17, you were asked about this, where you say:
14 "I concede that it may have been difficult for
15 a member of staff to know to whom to turn and how to
16 express their concerns, for fear of any consequences."
17 Is that a reference to the specific, in other
18 words, what happened --
19 A. It is.
20 Q. -- rather than just across the Trust?
21 A. Yes. It is a specific reference to the events that led
22 up to the GMC Inquiry.
23 Q. A recognition now that that may have been a problem?
24 A. Yes.
25 Q. You were asked about the Medical Director role. You
0129
1 explained that it required the number of sessions that
2 you put into it, the four sessions, and that was it was
3 eating, amongst other things, into your private life?
4 A. Yes.
5 Q. Was it also eating or intruding into your clinical
6 practice as well?
7 A. Yes. I was obliged to delegate some things that I --
8 before and since -- would have done myself.
9 Q. I think if the Panel has to look at the balance, your
10 four sessions, nonetheless, ate into your clinical life,
11 but you also made the point that the Medical Director
12 has to maintain clinical credibility?
13 A. I think he does, yes.
14 Q. What is the downside of devoting too many sessions to
15 the position of Medical Director?
16 A. I think you risk losing the confidence of the consultant
17 staff and being seen as rather remote.
18 Q. Just to try to avoid you having to put in another
19 statement dealing with this issue: you were asked to
20 think about the benefit or the value of having
21 a medically qualified Chief Executive. You said you
22 would think about it. You may not wish to answer these
23 questions, but traditionally, had the senior medical
24 staff been distrustful of hospital management in the
25 past, perhaps the more distant past?
0130
1 A. I think that is correct, and I think if I reflect on
2 the question a little more, maybe the best answer I can
3 give is that the advantage of having a medically
4 qualified Chief Executive is that they are more likely
5 at that particular moment to carry the confidence of the
6 consultant staff when making quite a fairly radical
7 change in the way we run the hospital.
8 Q. Obviously they speak the same language as the consultant
9 staff?
10 A. Yes.
11 Q. We have seen from other documentation that there were
12 considerable problems in bringing the consultant body
13 along with the management?
14 A. Yes, that is correct. Yes.
15 Q. Was the fact that Dr Roylance had a clinical background
16 important in achieving that?
17 A. I believe that it enabled him to have the confidence to
18 know that the staff believed in him and would follow
19 him.
20 MR MILLER: Thank you, Mr Baird. Thank you, sir.
21 THE CHAIRMAN: Thank you, Mr Miller. Mr Langstaff, for
22 tomorrow, first? If I can prevail on you just to give
23 us two seconds, Mr Baird, thank you.
24 MR LANGSTAFF: Tomorrow we are back to normal time at 9.30
25 in the morning, when we will hear from Mr Peter Durie,
0131
1 who was, for a while, the Chairman of the UBHT.
2 THE CHAIRMAN: Thank you, Mr Langstaff.
3 MR LANGSTAFF: Sir, I should add, I think, that last week
4 I mentioned that Mr McKinley would be present tomorrow.
5 Sadly, for certain reasons, he is no longer available
6 tomorrow so we shall not hear from him tomorrow; it will
7 be later.
8 THE CHAIRMAN: I am grateful to you for that. We shall in
9 due course hear from him.
10 First, may I on behalf of the Panel thank you,
11 Mr Baird, for giving us this afternoon. I repeat what
12 Mr Langstaff said: if there are other matters which you
13 think would help us, then please do let us know, either
14 yourself or through those who advise you. We are very
15 grateful to you for helping us this afternoon. We
16 reconvene tomorrow morning at 9.30. Thank you, ladies
17 and gentlemen. Thank you, Mr Langstaff.
18 (5.30 pm)
19 (Adjourned until 9.30 am on Thursday 17th June 1999)
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7 Examined by MR LANGSTAFF ................... 2
8 Examined by THE PANEL ...................... 127
9 Re-examined by MR MILLER ................... 127
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001