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FULL TRANSCRIPT

   1                      Day 31, 21st June 1999
   2   (10.38 am)
   3   THE CHAIRMAN: Miss Grey, good morning. I apologise that we
   4     are slightly late but there were one or two matters
   5     which we as a panel were dealing with before we came in.
   6   MISS GREY: Good morning, sir. This morning we have the
   7     evidence of Miss Deborah Evans, currently of the Avon
   8     Health Authority. If I could ask her to come and take
   9     the stand, please. She is represented today by
  10     Mr Michael Brooke QC.
  11        Miss Evans, we have been taking the evidence in
  12     the Inquiry under oath, so perhaps, if you would like to
  13     stand to affirm, please?
  14           MISS DEBORAH EVANS (AFFIRMED):
  15             Examined by MISS GREY:
  16   Q. Miss Evans, you have provided two statements to the
  17     Inquiry: one covering your responsibilities with the
  18     Bristol & Weston Health Authority and the other relating
  19     to an earlier period when you worked at the Bristol
  20     Royal Infirmary, because your experience spans both of
  21     those institutions, does it not? You started I think as
  22     an In-patient Services Manager at the BRI from 1987 to
  23     1989, where, after that, you transferred to the
  24     Bristol & Weston Health Authority as it was then to work
  25     on the contracting function as it was being developed

   1     under the NHS changes at that time.
   2        You were then, I think, initially the Contracts
   3     and Quality Manager, at that point half time, and
   4     subsequently full-time, when you became the Director of
   5     Contracting for Bristol & District Health Authority in
   6     April 1991.
   7        You then became a Director of Contracting when the
   8     three health authorities, Frenchay and Southmead, merged
   9     to form the Bristol and District Health Authority in
  10     October 1991?
  11   A. Yes.
  12   Q. You continued in that role in planning, contracting or
  13     commissioning of services until, in 1995, you moved to
  14     the new Avon Health Authority; is that correct?
  15   A. That is correct.
  16   Q. And you are currently the Executive Director of Avon
  17     Health Authority; is that right?
  18   A. Yes, I am.
  19   Q. You provided two statements to the Inquiry. You have
  20     also provided -- it is attachments to those
  21     statements -- considerable documentation. I think today
  22     you have also in front of you some notes which you may
  23     need to refer to if there are matters of detail you are
  24     being asked about?
  25   A. Yes.

   1   Q. The first statement you provided in relation to your
   2     time at the BRI -- just for the sake of the record, sir,
   3     I should say that that has been scanned in and is
   4     available as part of the evidence of WIT 159,
   5     Miss Evans, from page 390 onwards, but I do not propose
   6     to ask Miss Evans any questions about that unless there
   7     is anything else that others would like to raise.
   8        If we could move to your statement which covers
   9     your role as part of the District Health Authority, that
  10     starts at page 1 of WIT 159, if we could have that on
  11     the screen, please.
  12        That is the first page, the title page. If we
  13     could go perhaps firstly to page 17 of that statement,
  14     there is, I think, a small correction, really
  15     a typographical correction, you would like to make at
  16     paragraph 20 on that page.
  17   A. Yes. In that sentence towards the end of the sentence
  18     it says "and for adult cardiac surgery the workload
  19     almost doubled ..."
  20        That should read "adult cardiology".
  21   Q. Yes, otherwise it appears to be referring to the same
  22     thing twice?
  23   A. Yes.
  24   Q. With that correction, are the contents of your statement
  25     true to the best of your knowledge and belief?

   1   A. Yes, they are.
   2   Q. Just to make clear the parameters of your evidence
   3     today, I think it is right that you are not the person
   4     to be asked detailed questions relating to the finances
   5     of local district contracts; is that right?
   6   A. That is correct, and I believe that my colleague,
   7     Mr Healing, will be submitting a statement about
   8     financial matters.
   9   Q. Equally well, it is right, I think, that your statement
  10     does not cover in detail the history and policy issues
  11     relating to the split site for paediatric cardiac
  12     services at the BRI and the Children's Hospital?
  13   A. That is right. I believe that the Health Authority is
  14     submitting a separate free-standing statement about the
  15     split site.
  16   MISS GREY: And again, for the sake of the record, that was
  17     received by us last Friday and it will obviously be made
  18     available, but we have agreed, subject to your comment,
  19     sir, that given that no-one else has had yet the
  20     opportunity to look at that statement or to comment upon
  21     it, it would be appropriate to leave any matters raised
  22     by it for another occasion when no doubt there will be
  23     opportunities to ask any questions which arise.
  24   THE CHAIRMAN: Thank you, Miss Grey. Just to remind me,
  25     and maybe for the benefit of others, we are making

   1     a specific and separate number of days available to look
   2     at split sites, is that not the case?
   3   MISS GREY: That is the intention, sir.
   4   THE CHAIRMAN: So we can take it then?
   5   MISS GREY: Precisely.
   6        Finally, it is also right, is it not, that you are
   7     not the person directly concerned with looking at the
   8     reports received from the UBHT or any other institution
   9     with which the district had contracts during the time
  10     with which we are concerned, concerned with clinical or
  11     medical audit?
  12   A. Yes, that is correct. That was the province of our
  13     public health department, and I believe that you will be
  14     receiving a statement from Dr Ian Baker and also from
  15     Dr Keiran Morgan, our Director of Public Health.
  16   Q. So those are, as it were, the "not"s of your evidence.
  17     What you can answer questions about are the arrangements
  18     for the commissioning of services, cardiac services
  19     particularly, from the UBHT in particular because they
  20     are the years we are concerned with, 1991 to 1995?
  21   A. That is right.
  22   Q. If we turn to page 5 of your witness statement, you set
  23     out there first of all the background that you had at
  24     the BRI and then, in the second substantial paragraph of
  25     that page, you talk about the core of your job being to

   1     establish and lead the contracting process within
   2     national guidelines and to contribute to the development
   3     of health care purchasing strategies and service models.
   4        Then, in the subsequent paragraph, you talk about
   5     the change in language as contracting became
   6     commissioning at a later date.
   7        That is a very broad view of the job that you were
   8     undertaking, but again, it is right, is it, that we must
   9     bear in mind that your detailed involvement was with
  10     services for the over 1s rather than the under 1s?
  11   A. Yes. That is right, and that was because the service
  12     for the under 1s was purchased by the NHS Executive
  13     because it was designated as a supra-regional service
  14     for part of the period until the service was
  15     de-designated.
  16   Q. I think we will come back to the question of who had
  17     responsibility for that service at a later stage, but if
  18     we move on to page 9 of your statement, you do there
  19     describe in more detail the arrangements for
  20     supra-regional services and you say there, as you have
  21     just explained, that the Department of Health
  22     commissioned the services there.
  23        If we turn down to paragraph 4 of that statement,
  24     you say there that the Bristol & Weston Health Authority
  25     as a host provider had to include the service in its

   1     forward plans and make premises, staff and equipment
   2     available for the service.
   3        That implies that there might have been a degree
   4     of cross-subsidisation going on between the two
   5     authorities. Is that what you meant to imply, or would
   6     that be a misunderstanding of that paragraph?
   7   A. I did not mean to make any inference about
   8     cross-subsidisation; I was simply reflecting, and this
   9     would apply to the period before 1991, that
  10     Bristol & Weston Health Authority was the host health
  11     authority for paediatric cardiac services, and as such,
  12     although the funding came from the Department of Health,
  13     the annual programmes for the Health Authority would
  14     make reference to the service and clearly premises and
  15     staff and buildings were part of that annual programme
  16     process.
  17        So it would be acknowledged in those annual
  18     programmes.
  19   Q. But is that an acknowledgment that is merely in words,
  20     or is that also a financial acknowledgment?
  21   A. I am not an expert on how the funding of supra-regional
  22     services occurred, but my assumption would be that they
  23     would have been funded in every respect by the centre
  24     and therefore should not imply or incur extra costs on
  25     the Health Authority locally.

   1   Q. If we go on to paragraph 5 of that page, you set out the
   2     fact that after de-designation, the funding was
   3     transferred from the Department of Health to the regions
   4     for delegation to the Health Authority.
   5        There is a reference there to a letter which we
   6     will find at HA(A) 11/23. That is a letter from Mr Nix
   7     to yourself setting out a certain degree of uncertainty
   8     at this stage -- it is dated September 1993 -- but it
   9     does say at the end of the third paragraph that it is
  10     also likely that purchasers will be required to buy an
  11     equivalent service from UBHT in at least the first year.
  12        That proved to be the case, did it not?
  13   A. Yes, it was the case, and that was also the convention
  14     which applied across the country when any service became
  15     de-designated.
  16   Q. So in other words, there was a steady state giving
  17     a degree of security to the unit concerned for the first
  18     year of de-designation?
  19   A. That is right.
  20   Q. And that would have covered the financial year 1994 to
  21     1995. Thereafter, of course, certain changes were made
  22     to the services covering under 1s at the UBHT. Perhaps
  23     you can fill us in on those?
  24   A. Yes, I think that it was around that time that the
  25     children were cared for in the Children's Hospital

   1     rather than in the BRI. The general Paediatric
   2     Intensive Care Unit at the Children's Hospital was
   3     expanded so that it could include intensive care for
   4     children who had had cardiac surgery, and I think around
   5     that time, during that financial year, 1995/96, a new
   6     specialist paediatric cardiac surgeon was appointed and
   7     took up post.
   8   Q. It is also I think right to record that it was around
   9     that time that concerns became a matter of public
  10     knowledge, at least to some degree, about the
  11     performance of the unit.
  12        Are you able to help us as to whether or not
  13     knowledge of those concerns from your perspective -- of
  14     course you can only speak to your own knowledge of these
  15     events -- predated or postdated the developments that
  16     you have just summarised?
  17   A. I had no knowledge of those events before they were made
  18     public. I knew that it was planned that the children's
  19     work would go to the Children's Hospital, and I knew
  20     that a new surgeon had been appointed, and that was all
  21     I knew.
  22   Q. Does it follow, or are you implying, before you were
  23     made aware of any public concerns about performance?
  24   A. I knew about the intensive care arrangements changing
  25     and the surgeon coming, I think before I knew that there

   1     were any problems, but I believe that in her statement
   2     to the Inquiry, our Chief Executive describes the point
   3     at which she was informed about some issues, and
   4     clearly, the correct way for that sort of information to
   5     be transmitted formally would be to our Chief Executive.
   6   Q. The relevance of the question, Miss Evans, is simply
   7     this: the Inquiry might have been interested, perhaps,
   8     in the way in which the contract for the under 1s was
   9     handled by the Health Authority after, as it were, the
  10     year of steady-state continuity, but does the
  11     combination of the changes to the service that was being
  12     delivered, plus the concerns that were being expressed,
  13     make it difficult for you to assess the nature of any
  14     changes that were apparent in the Health Authority's
  15     handling of the contract?
  16   A. Yes. I think it is difficult to say in retrospect, how
  17     would we have handled the contract for the under 1s, had
  18     not these other events intervened.
  19   Q. If we go down a little further on that page we see there
  20     in the substantial paragraph in the middle, Mr Nix is
  21     writing that the over 1s are covered in the current
  22     service contracts and that to large extent the
  23     artificial barrier between the under and over 1s is
  24     confusing and distorts prices and billing processes.
  25        Are you able to help us on the extent of that

   1     distortion, or its nature?
   2   A. I do not think so.
   3   Q. That is a question that should be directed more to your
   4     financial colleagues?
   5   A. I think so. I think that would be more appropriate.
   6   Q. If we can go on in your statement to paragraph 1.4.3,
   7     which is over the page at page 10, we see there some
   8     comments you made on the fact that the UBHT, before it
   9     became operational in April 1991, set up a structure of
  10     clinical directorates. You comment, of course, that
  11     that was widespread across acute Trusts in the NHS at
  12     the time, and that it offered clear managerial and
  13     clinical points of contact from the point of view of the
  14     district authority.
  15        Do you have experience of handling contracts with
  16     other Trusts across the district or further afield
  17     during the role you occupied from 1991 to 1995?
  18   A. Yes. In the course of any contracting cycle, I would be
  19     mainly involved with the Trusts that fell within the
  20     Health Authority's catchment area, and those were
  21     Frenchay Healthcare Trust, Southmead Healthcare Trust,
  22     UBHT and Weston. I was also involved in discussions
  23     every year with the Trusts in Bath and as far as acute
  24     services are concerned, that would be the Royal United
  25     Hospital in Bath.

   1   Q. Was the Clinical Directorate structure the structure
   2     adopted by each of those Trusts as well?
   3   A. To varying degrees.
   4   Q. How did the structure at the UBHT, then, compare,
   5     contrast, with that adopted by these other Trusts?
   6   A. I think that the Clinical Directorate system, certainly
   7     between 1991 and 1995, was most fully developed at UBHT
   8     compared with the others. I would say with Frenchay
   9     being a close second.
  10   Q. What do you mean by "most fully developed"?
  11   A. Two things, really: one is in terms of a system whereby
  12     clinicians were the Clinical Directors responsible for
  13     a specialty or group of specialties, and were thereby
  14     very much involved in the management of those
  15     specialties, but also very much involved in the dialogue
  16     with purchasing health authorities about what the Trust
  17     should be providing and how that might work.
  18        So I think that would be one of the key points.
  19        The second one would be something about the
  20     implications of a Clinical Directorate structure for the
  21     management of a Trust, and, in the UBHT's case, being
  22     such a large Trust with so many specialties, that led to
  23     a fairly federal structure of clinical directorates.
  24   Q. Again, can you expand on the meaning: what you mean by
  25     the word "federal"?

   1   A. What I mean is that the UBHT was a very substantial
   2     Trust both in financial terms and in terms of the scale
   3     of the services and the number of services it provided,
   4     and I think that meant that in terms of its
   5     organisation, it made good sense to have strong local
   6     management at directorate level.
   7   Q. So what you are commenting on, perhaps, by the use of
   8     the word "federal" is the extent to which management was
   9     devolved within the UBHT; is that fair?
  10   A. Yes.
  11   Q. Equally well, if one went back to your statement about
  12     your involvement in the BRI up to 1989/1990, the comment
  13     you made there was that the BRI was "well led", it was
  14     well managed and highly professional?
  15   A. Yes.
  16   Q. It seems from the answers you have just been giving
  17     about the way the Clinical Directorate structure was set
  18     up that you also have a positive view as to how that
  19     functioned when you were dealing with it from the other
  20     end, as it were, with the Health Authority.
  21   A. I think I have a very positive view about the
  22     involvement of clinicians in management and the extent
  23     to which that was developed. I think it is very
  24     difficult, as a purchaser, to have a completely
  25     comprehensive view about the management of services that

   1     happen in provider Trusts.
   2   Q. But picking up the point where you saw it, which was the
   3     point you make in your statement about the directorate
   4     system providing you with clear managerial and clinical
   5     points of contact, your experience was that clinicians
   6     were involved with the negotiation of contracts, with
   7     the District Health Authority?
   8   A. Very much so.
   9   Q. Because, if we look at page 123 of your witness
  10     statement, we see there the beginning of guidance, and
  11     it is illustrative only, I am sure you will be able to
  12     tell us, that this sort of theme was repeated many times
  13     throughout the same period. If we look at this guidance
  14     for the 1994 to 1995 contracting cycle, and turn over
  15     the page to page 125, down towards the bottom of the
  16     page, paragraph 10, there is the NHME saying that
  17     purchasers/providers "must ensure that doctors and
  18     professionals from providing units are actively involved
  19     in the contracting process."
  20        Was that something you felt was achieved in your
  21     dealings with the UBHT?
  22   A. Yes. I think it was achieved.
  23   Q. And does that comment apply with greater or lesser force
  24     when you are looking back over your involvement with
  25     cardiac services, in particular?

   1   A. I would say that in the cardiac services field, the
   2     clinicians were even more closely involved than in many
   3     of the other specialties and disciplines.
   4   Q. Is there any particular reason for that, do you think?
   5   A. I think probably there are a number of reasons for it.
   6     One is that it was, as I described in my statement,
   7     a fairly contentious area between the purchasing Health
   8     Authority and the clinicians about levels of investment,
   9     and about the type of investment, the nature of what we
  10     were wanting to commission for our population. So there
  11     was a very active debate that went on fairly
  12     continually, particularly on the adult side, about
  13     that.
  14   Q. You mentioned several reasons. Is that really the one
  15     you would like to highlight, or are there any others?
  16   A. There may be a case that says that specialists such as
  17     cardiac surgeons or perhaps neurosurgeons, perhaps renal
  18     physicians, feel themselves a strong need to be directly
  19     involved in discussions and put forward their case, may
  20     well be in contact with colleagues up and down the
  21     country, and may have a feel for the potential that can
  22     arise from being involved with the Health Authority as
  23     commissioners.
  24   Q. Because the implication of some of these documents is
  25     that purchasers had to work hard to get clinicians

   1     involved, but in fact, if we turn over the page to
   2     page 132, the other side of the coin is commented upon
   3     which is that just as one wants to get clinicians
   4     involved, if you look at paragraph 38, so if we come
   5     down a little bit, the involvement of clinicians is
   6     mentioned again. There is perhaps set out there the
   7     view of clinicians that "there remains the view that
   8     contract negotiations centre too much on finance and
   9     activity, not enough on quality and development of
  10     health policies. Many clinicians express frustration
  11     with the negotiating teams which are often not
  12     sufficiently clinically informed or are made up of
  13     predominantly finance or business planning personnel.
  14     Discussions in many cases are perceived to be office
  15     bound with little time spent with GPs or in hospitals."
  16        I put that to you in order to put the other side
  17     of the coin, as it were. To what extent do you think
  18     the District Health Authority was successful in making
  19     sure that it could undertake a genuine dialogue and
  20     understand the things that clinicians were attempting to
  21     say to it when making out their case for particular
  22     services?
  23   A. This review of purchasing that we are referring to at
  24     the moment was a very comprehensive review which sought
  25     opinion from all health authorities and a good selection

   1     of Trusts, so I am not surprised to see this feed-back.
   2        I think that it would be fair to say that whilst
   3     the Health Authority was very involved in cardiac
   4     services, we were deliberately, and partly due to our
   5     size, selective about how many services we dealt with in
   6     detail every year.
   7        So I think it would be possible to find some
   8     clinicians in our district who said that for their
   9     specialty, or their service, they did not have the level
  10     of involvement and the scrutiny that perhaps they felt
  11     their service deserved.
  12        I would be surprised if the clinicians in cardiac
  13     services felt that they had insufficient dialogue, but
  14     I would not be surprised if they felt a frustration
  15     about financial matters.
  16   Q. You are drawing out there a contrast between the
  17     district's attitude to cardiac services and perhaps to
  18     certain other areas as well, and its attitude to perhaps
  19     the full range of the services which it had to purchase
  20     or commission on behalf of its population.
  21        Can you just expand a little on the nature of that
  22     contrast and the priority that was attached to cardiac
  23     services during 1991 to 1995?
  24   A. I think that there were some specialties which, for
  25     a variety of reasons, we were involved in detailed

   1     discussions with every year, and adult cardiac services
   2     is one of those.
   3        For various reasons -- and I hope that I have made
   4     these fairly explicit in my statement -- there was an
   5     issue about investment levels and that meant that in our
   6     dialogue with GPs, which was really a cornerstone of
   7     most of our work, we were often getting feed-back from
   8     them about concerns about patients having to wait a long
   9     time for treatment and so on. So there were lots of
  10     reasons why we were interested in this specialty and
  11     those reasons continued year on year, despite our
  12     priority, the priority that we gave the specialty in
  13     investment terms. I think that is because heart disease
  14     is such a big issue, both nationally and locally, in
  15     terms of premature death and illness.
  16        So it was an issue that was always with us and
  17     therefore, always getting our attention.
  18   Q. Two things: you have mentioned concerns about waiting
  19     lists. I think you make it clear in your statement that
  20     so far as the Authority was aware, that was a concern
  21     that related to adults rather than to children?
  22   A. Yes, very much so.
  23   Q. Furthermore, does it follow from what you have just
  24     said that if we look at the activity levels, to put it
  25     like that, of the district in the monitoring of cardiac

   1     services, that we need to be aware of the fact that this
   2     relates to a particularly high profile specialty and
   3     that one would not necessarily find the same levels of
   4     engagement right across the sphere of the Health
   5     Authority's work?
   6   A. That is certainly the case, and I think there are two
   7     reasons for it: one is that as purchasers or
   8     commissioners of health care, it is our responsibility
   9     to focus on the particular health needs of our
  10     population, and therefore, heart disease would rank
  11     highly.
  12        Secondly, of course, a Health Authority has
  13     limited personnel. We were, and still are, the cheapest
  14     Health Authority in the country in terms of per capita
  15     spend on Health Authority management costs, so with
  16     limited personnel, one has to be selective about the
  17     areas which one can address.
  18   Q. How do you think, with the benefit of hindsight, the
  19     attention focused on adults compared to the attention
  20     that was given to the service for the over 1s to age 16
  21     in cardiac services?
  22   A. The service for the over 1s was very small and I think
  23     I say in my statement that there were between 22 and 36
  24     children treated each year, so it was very tiny. And
  25     although it was a specialty in which we would have

   1     discussions with the cardiologists and the surgeons, it
   2     was not one of the areas that we were continually
   3     working on.
   4   Q. If we come back to the concern being expressed by
   5     clinicians in the feedback process about the
   6     understanding of authorities, their arguments and
   7     concerns, if we look at a document produced by the Audit
   8     Commission in 1997, so later than our terms of
   9     reference, it is a document on the commissioning of
  10     specialised services in the NHS. It is to be found
  11     attached to WIT 46. The title page is 432.
  12        That is the report which I think you have had an
  13     opportunity to look at?
  14   A. Yes, thank you.
  15   Q. If we look at page 445, towards the bottom of the page,
  16     "Why are specialised services difficult to
  17     commission?", there is there set out a series of
  18     characteristics of specialised services that perhaps
  19     posed particular difficulties for health authorities.
  20     The scale of the services in particular is emphasised
  21     there.
  22        If we turn over the page to 446, at the top, there
  23     is a reference there to health authorities not always
  24     having the specialised knowledge to understand these
  25     services and that the expertise was often only found in

   1     the centres themselves.
   2        Do you think those observations apply to the case
   3     of cardiac services?
   4   A. I think that paragraph represents a dilemma which always
   5     exists, in that clinicians feel themselves to be the
   6     experts in service delivery, and they also feel that
   7     they are the most up-to-date with service developments.
   8        Whilst I think that we had good involvement
   9     through our public health department and good access to
  10     professional advice from them, I think that part of the
  11     discussion between the public health department and the
  12     clinicians would be about whether it was appropriate for
  13     us to put weight, maybe exclusive weight, on the
  14     published evidence of trials and firm data which might
  15     be slightly out of date, whereas clinicians would be
  16     arguing that new treatments that they were using were
  17     the cutting edge and the way forward and so on. So
  18     there was always that tension.
  19   Q. How much expertise did the Health Authority have access
  20     to in order to be able to engage on equal terms with the
  21     clinicians in these sorts of debates?
  22   A. I am sure that my public health colleagues will describe
  23     this to you in more detail, but we have a system within
  24     the Health Authority where each public health consultant
  25     concentrates on certain specialties or disease areas, so

   1     in our case Dr Baker is the person who specialises in
   2     coronary heart disease and who was involved in the
   3     contracting negotiations every year with the cardiac
   4     surgeons and the cardiologists.
   5        So his role would be about knowing what published
   6     evidence there was available, being able to refer to the
   7     literature and interpret it, and being able to have
   8     a pretty close dialogue with the clinicians.
   9        We also have, in Bristol, a health care evaluation
  10     unit and people from that health care evaluation unit,
  11     a research unit, were also involved from time to time
  12     with the cardiac services in looking at aspects of
  13     cardiac care. I know that consultants in health
  14     medicine from neighbouring health authorities, for
  15     instance, Somerset, did some collaborative work with us
  16     with this specialty. I think we devoted a lot of expert
  17     time to it ourselves.
  18   Q. So you think, really, you would give yourself
  19     a reasonably good rating in having managed to rise to
  20     that particular challenge? I think you are nodding. It
  21     is put in slightly tendentious terms.
  22   A. I would, and I am sure this is an area you will rightly
  23     want to pursue with my public health colleagues, and
  24     perhaps with other witnesses.
  25   Q. I was going to ask, would that answer hold good also for

   1     the area of children's services?
   2   A. I think the same answer applies, really, in the sense
   3     that Dr Baker's responsibility for looking at cardiac
   4     services applied to children as well as adults, although
   5     I think that the adult area was one where perhaps the
   6     interest of outside research units was less evident.
   7   Q. It was less evident?
   8   A. Yes. In other words, I am not sure that our local
   9     health care evaluation unit were involved with the
  10     service for children in the way that they were for
  11     adults. That, of course, relates back to coronary heart
  12     disease and its importance.
  13   Q. If we turn back to your statement at page 11,
  14     WIT 159/11, you set out there the development of
  15     contracting and the purchasing role of the District
  16     Health Authority from 1991 to 1995.
  17        This was obviously the point at which the
  18     purchaser/provider split was being developed within the
  19     NHS. Can you just tell us from your perspective what
  20     the main challenges that were being faced by the
  21     district in this area were at the time?
  22   A. There were many challenges. I think that there was an
  23     enormous technical change in the Health Service at that
  24     time, which was to do with being able to track all the
  25     patients that were resident in a particular Health

   1     Authority and to follow them through hospital care and
   2     turn all of that into service agreements; but also,
   3     looking at the public health side of it, health
   4     authorities had a responsibility for the first time only
   5     to look at the needs of their local populations and not
   6     to be involved in running services. So I think the
   7     changes gave rise to an increased and more particular
   8     focus on local health needs from a public health point
   9     of view, which was helpful, and I think the other side
  10     of the separation from the provision of services meant
  11     that managers and clinicians had to go through a huge
  12     cultural change in getting used to huge organisations
  13     working together on the planning of health care.
  14   Q. If I could go back to the first part of that answer, you
  15     talked about the technical challenge of tracking the
  16     movement of patients throughout the district.
  17   A. Yes.
  18   Q. Was the district particularly well placed to rise to
  19     that particular challenge in 1991, as compared to other
  20     regions or districts in the country?
  21   A. The South West Regional Health Authority had piloted an
  22     approach during, I think, 1989/90/91, which was all
  23     about that. It was all about tracking patients
  24     through. So when, from 1991/92, we were required to
  25     capture those "patient flows", as they were called, into

   1     service agreements, I think the hospitals and the health
   2     authorities in the South West Region were in a better
   3     position to do it than probably anywhere else in the
   4     country, because we already had a single computer system
   5     which captured it according to standard processes.
   6   Q. What was the name of the system that you were using?
   7   A. I cannot remember.
   8   Q. We are talking generally about the patient
   9     administration system and the --
  10   A. Yes. It drew the data from the individual hospitals,
  11     patient administration systems.
  12   Q. If we could look at the Health Authority document
  13      HA(A) 17/58, this -- I am sorry it is not the first
  14     page, but it is part of a minute, I think, from
  15     1989/1990. It sets out some of the challenges that were
  16     facing the authority at the time.
  17        If we go down a little, perhaps, to "Setting
  18     quality standards", there is a discussion there of the
  19     fact that early discussions showed there is a dearth of
  20     monitoring of service performance which can be used in
  21     the contracting process. Then the emphasis as a result
  22     has tended to be on input and process measures. Then
  23     they talk about selectivity as a result of early
  24     contracting and that "For several of the above, the
  25     first task will be to establish what happens at

   1     present".
   2        Can you help us as to the extent of the
   3     information that was available or perhaps the extent of
   4     the challenge faced by the district in trying to assess
   5     quality standards as part and parcel of its contracts?
   6   A. I think the first point to make was that the patient
   7     administration systems and the means by which we could
   8     process them across the region, which was called "Centre
   9     Link", allowed us to look at certain limited process
  10     measures, so, for example, we could use the data to look
  11     at in-patient waiting times and outpatient waiting
  12     times, although I think at the beginning of the period
  13     a lot of the outpatient clinics were not on a computer
  14     system, but certainly by the end of the period, we had
  15     fairly comprehensive outpatient waiting time data.
  16        So we could look at those things. We could look
  17     at cancellation rates, although I think the methodology
  18     for collecting that improved over time. So there were
  19     some very basic process measures which we could look at
  20     using computer systems. But we could not look at
  21     anything to do with audit and outcomes through computer
  22     systems remotely.
  23        I think, as far as many aspects of quality
  24     monitoring were concerned, we relied on the Trusts to be
  25     active in those areas and the Trusts to report to us

   1     from their own data; we could not take it from the
   2     computers; we could not do it remotely.
   3   Q. Was there an attitude or a philosophy about the
   4     respective role of Trust and Health Authority in
   5     relation to audit or standards within a hospital that
   6     lay behind that answer?
   7   A. Certainly -- and I think this comes nationally -- as
   8     part of the purchaser/provider separation, as it was
   9     called, there were a large number of areas which were
  10     regarded as not being the legitimate province of
  11     purchasers. That would include, for example, anything
  12     to do with staff training or numbers of staff on ward
  13     areas. Those were regarded as being provider/management
  14     issues, and purchasers were explicitly required --
  15     I think both in national and regional documentation --
  16     not to try to become involved in those areas of quality.
  17   Q. What about quality in terms of outcome of services, the
  18     quality of the service delivered? What was the attitude
  19     in relation to that?
  20   A. I think that the view in relation to that was that the
  21     primary responsibility for outcome and clinical quality
  22     of service lay with Trusts. That was one of their key
  23     roles, one of their main jobs, and they reported to the
  24     centre through the regional health authorities and later
  25     what was called the "regional outpost" of the NHS

   1     Executive about quality and about financial matters. So
   2     that was their province. I think, at the beginning of
   3     the period at any rate, audit was seen as being
   4     a professional activity. I think it was seen as being
   5     educative about learning and reviewing things, and
   6     I think it was seen, therefore, as not being the
   7     province of managers and not being the province of
   8     purchasers.
   9   Q. Both managers within the hospital, then, and purchasers
  10     outwith the hospital?
  11   A. Yes. I think initially it was regarded as being purely
  12     professional and not something that Trust managers
  13     should be involved in the detail of, other than to know
  14     that it was happening. I think that changed over the
  15     period between 1991 and 1995.
  16   Q. We will come back to that, I think, in a little more
  17     detail when we look at the part of your statement which
  18     deals with the monitoring that was being undertaken by
  19     the authority. For the moment perhaps we could go back
  20     to your statement and page 11, where you talk about some
  21     of the early results of the way in which the
  22     purchaser/provider separation worked.
  23        Towards the bottom of the page, paragraph 2.1.6.
  24     You set out at 2.1.5 the difficulties in switching
  25     contracts, and then you set out in the following

   1     paragraph the results that it had the effect of focusing
   2     attention either on remodelling services within an NHS
   3     Trust or on ways of developing services using the
   4     marginal annual increase in funding to the NHS.
   5        When the purchaser/provider separation was set up,
   6     there was a lot of talk, of course, of introducing
   7     competition between providers for the provision of
   8     services, but later commentary on the changes perhaps
   9     suggested that that had not taken place to such an
  10     extent as might perhaps be envisaged at least by some
  11     commentators.
  12        What was your experience in relation to cardiac
  13     services in particular of the effect of the changes?
  14   A. I think the first point to make is that health
  15     authorities were expected, in placing service
  16     agreements, to reflect the referral patterns of their
  17     general practitioners. That was the basis on which all
  18     service agreements were made and we did that. The
  19     geography of Bristol and District is such that work
  20     tends to flow into the central hospitals, and UBHT was
  21     the only one providing cardiac services, so naturally,
  22     that is where patients were treated. And the Health
  23     Authority, therefore, placed its contracts with them.
  24     I think throughout the period we placed very little work
  25     outside. I think for most of the period there was an

   1     issue across the Health Service in England about
   2     capacity for cardiac surgery, in that I think demand was
   3     exceeding supply, not the other way round. So it was
   4     less a case of purchasers shopping around and going to
   5     other places than about being concerned to try and
   6     secure the workload that you needed to treat your local
   7     population.
   8   Q. And that is the background, then, against which you were
   9     working with the UBHT to increase the throughput of the
  10     unit year on year, and you have given us data, of
  11     course, on the extent to which that succeeded and also
  12     of the additional investment made by the district in
  13     cardiac services?
  14   A. Yes.
  15   Q. One of the aspects of the divide was that, again, the
  16     initial experience of at least some purchasers may have
  17     been that information about the services lay solely in
  18     the hands of the providers rather than the district.
  19        On the other hand, Mr Nix has given evidence to
  20     the Inquiry that, whilst it is true that expertise in
  21     the specialties that the authority was purchasing did
  22     lie with the providers, and that all the cost data was
  23     with them as well, nevertheless both sides were
  24     supportive and both sides had an interest in developing
  25     a co-operative relationship which worked.

   1        Was that your experience of dealing with the UBHT
   2     in these years?
   3   A. Yes, it was.
   4   Q. So would you say there were any problems created by the
   5     imbalance in who held the cost information or was it
   6     something that worked nonetheless?
   7   A. I think that the health authorities had a limited
   8     picture about the way in which Trusts deployed their
   9     resources and about pricing and so on. So I do not
  10     think we had a complete picture on it. But certainly,
  11     in terms of the dialogue with the UBHT, I think we had
  12     a constructive and fairly challenging relationship,
  13     really.
  14   Q. If we turn to page 17 of your statement, briefly, to
  15     paragraph 2.2.22, halfway through, you set out there, in
  16     the last sentence, that the usual practice of the
  17     authority was to place contracts for elective work with
  18     non-NHS Trusts when local capacity was completely
  19     committed.
  20        Can you tell us why that policy was developed?
  21   A. I think it was partly because -- this is reflected in
  22     some of the work of the Audit Commission, and in
  23     particular, a report that they did about commissioning
  24     specialised services, which we have referred to
  25     earlier. That was, that health authorities needed to

   1     work with their providers to ensure that they could
   2     develop services over a number of years. In the
   3     situation in which we were, where we had a baseline
   4     contract for a number of specified procedures with the
   5     UBHT, but every year we were placing substantial waiting
   6     list initiatives with them, and the following year we
   7     would increase our investment and need more capacity, it
   8     made sense to work with one provider and help that
   9     provider to develop, rather than placing contracts all
  10     over the place and losing the ability to guarantee an
  11     increase year on year.
  12   Q. If we turn, then, to those contracts in a little bit
  13     more detail, the first that followed the formal
  14     introduction of the purchaser/provider split, although
  15     there were some shadow agreements before that, is to be
  16     found at HA(A) 11/245.
  17        That, I think, is a document that you would
  18     recognise.
  19   A. Yes.
  20   Q. If we turn down a little, scrolling through, we see
  21     at paragraph 4.1 that there are some "x"s where you
  22     would expect to see numbers filled in in those
  23     paragraphs. Does that indicate that this contract is
  24     a draft, or what does it show?
  25   A. I think that by the time we had to finalise the contract

   1     in that year, we had not finished talking between the
   2     Public Health and the consultants about the ratio of
   3     open to closed procedures.
   4   Q. Would that indicate that there is another draft or
   5     another more complete version, or did the negotiations
   6     stop there?
   7   A. I think they had to stop there because time ran out.
   8   Q. So can you explain the way in which this particular
   9     contract worked -- I think it has been described as
  10     a "sophisticated block contract" in some of your
  11     passages in your statement.
  12   A. Yes. Sophisticated block contracts were contracts where
  13     every month through the year we paid a fixed sum which
  14     was determined at the beginning of the year for an
  15     amount of work. We would identify certain procedures,
  16     not all procedures but certain key procedures, so for
  17     adults and cardiac surgery we would identify valve
  18     repair operations and coronary artery bypass grafts and
  19     we would say how many of them we wanted to have.
  20        I think the objective was to have sufficient
  21     control over the workload from a purchasing point of
  22     view, that we felt that we were reflecting our
  23     population's needs, without tying it down so tightly
  24     that there was no flexibility should, for example, there
  25     be an increase in emergency admissions.

   1   Q. What happens if there was an increase in emergency
   2     admissions and the numbers being referred to the BRI
   3     exceeded the numbers that you had contracted for?
   4   A. As long as it was not a really huge amount, such that
   5     the Trust could not cope at all, they would absorb the
   6     extra and then we would have discussions in our next
   7     contracting round about whether the contract needed to
   8     be changed to reflect, say, a year-on-year growth in
   9     emergencies. Actually, there was a year-on-year growth
  10     in emergencies in that specialty.
  11   Q. So in effect you are saying that the Trust took the
  12     risk in each contracting year for there being an
  13     additional number of cases referred on to it, and did
  14     not receive any additional income that year if it
  15     treated more patients than had been envisaged under the
  16     contract?
  17   A. But that was the arrangement, and there was also
  18     a clause in the contract which basically said words to
  19     the effect of, "if there is an overwhelming year-on-year
  20     increase, the purchaser and the Trust will have
  21     discussions about how to deal with it", and, for
  22     example, that happened occasionally in general emergency
  23     medical admissions.
  24   Q. But not, I think, in cardiac surgery?
  25   A. That is right.

   1   Q. And conversely, it follows, does it, that if a smaller
   2     number of cases were referred on, the Health Authority
   3     could not expect to claw back any of the sum that it had
   4     committed to the UBHT, but the hospital, instead, would
   5     stand to gain in those circumstances?
   6   A. That is right, and that did not happen very often in
   7     adult cardiac services.
   8   Q. If we turn through that contract just to familiarise
   9     ourselves with it, we can see in particular if we move
  10     on to page 247, that there are standards set out for
  11     admissions and patient stay and in particular it says
  12     that parents will be able to stay with children on their
  13     ward if they wish, and there are further standards set
  14     out.
  15        It is right, I think, that you have given us
  16     details of the standards relating to the care for
  17     parents or families that were expected of the UBHT
  18     throughout this period?
  19   A. Yes, it is, and I think that it changed slightly over
  20     the period and we were more explicit, I think, in
  21     subsequent service agreements about aspects of care for
  22     children.
  23   Q. If we then turn over, we see, at page 248, "Tertiary
  24     referrals". There you say that the tertiary referrals
  25     will be kept to a minimum and are not expected to

   1     increase. We will come back to that, if I may, later.
   2        Then in paragraph 11, "The care of children",
   3     that, I think, is something dealt with in the separate
   4     statement to which we have already referred.
   5        Towards the bottom of the page, paragraph 14.1,
   6     "The providers will have quality assurance systems
   7     which include elements of quality control,
   8     identification of service deficiencies, and mechanisms
   9     for correcting and reviewing problems."
  10        Is that the sort of area of the UBHT's quality
  11     assurance programmes that you were involved in
  12     monitoring in the monitoring reports that you have
  13     referred to later in your statement?
  14   A. Yes, it is, and we had a system where the Trust sent us
  15     monitoring reports and we would give them feedback on
  16     those monitoring reports. I think in our feedback for
  17     the first year, 1991/1992, we drew particular attention
  18     to the fact that in order for this system to work, the
  19     Trust would need to take responsibility for setting its
  20     own quality assurance framework and for making sure it
  21     was reviewing its services against its own framework.
  22   Q. We will come to those specific documents later. If we
  23     turn over the page to "Medical audit", we see there that
  24     the standards for audit are set out in some detail, in
  25     particular, at paragraph 15.2, the audit of outcome is

   1     expected to include measures of 30 day mortality, one
   2     year mortality and one year symptomatic state.
   3        Are those standards ones that were widely accepted
   4     and already in place at the time, as far as you know?
   5   A. I think that they had been discussed and agreed with the
   6     clinicians; they were not in place at the time and
   7     I think they had to be regarded as aspirational rather
   8     than currently in existence.
   9   Q. Because I think we can look at Mr Wisheart's reaction to
  10     this contract at HA(A) 11/254, if we could just go to
  11     that briefly. This is a letter, we will see the second
  12     page in a moment, but it is from Mr Wisheart, who is
  13     reacting to this contract. He has been asked to sign it
  14     for the year beginning 1st April. Lest his signature
  15     should be construed as his agreement to the contract, he
  16     states various reservations and he points out, at
  17     paragraph 1 that the numbers have not been put in.
  18     I think we have already discussed that. Then there is
  19     already a question of being overspending in the
  20     Directorate of Surgery, and then down at paragraph 3,
  21     there is a concern about the resource implications of
  22     the paragraphs we will go back to in a moment on
  23     monitoring and reporting, and then, in particular, he
  24     talks in relation to paragraph 15 -- this is what we
  25     have just been looking at -- the audit achievements are

   1     being established, but may not operate fully from
   2     1st April. Then a goal as to paragraph 19.2.
   3        This letter comes from the Health Authority
   4     documentation, so it obviously reached you. It records
   5     a number of really quite significant reservations to the
   6     letter of the contract. How would the Health Authority
   7     have regarded those reservations or reacted to them?
   8   A. I do not think that any of the content of the letter
   9     came as a surprise to us, because I think the issues had
  10     all been raised with us in contract discussions.
  11     I think on the first page you can see in my handwriting
  12     that I have written that I have reassured the Trust
  13     about one aspect of concerns.
  14        I think, as far as the question about medical
  15     audit is concerned, Mr Wisheart had led the discussions
  16     on this particular specialty and he had been very
  17     positive about the need for development of medical
  18     audit, but I think he is reflecting to Dr Roylance that
  19     those were intentions and they were not yet in place.
  20   Q. But that was then something that was understood and
  21     accepted by the Health Authority, at least at this stage
  22     of establishing contracts?
  23   A. Yes, it was.
  24   MISS GREY: I think, Miss Evans, that is probably
  25     a convenient moment for a break, if that is acceptable

   1     to the Panel. Could we perhaps break for a quarter of
   2     an hour?
   3   THE CHAIRMAN: Yes, thank you. We will break now and
   4     reconvene at noon. Thank you very much.
   5   (11.45 am)
   6               (A short break)
   7   (12 noon)
   8   MISS GREY: If we could go back, please, to the contract we
   9     were looking at at HA(A) 11/249, this is the service
  10     agreement once more. We were looking at medical audit
  11     and the audit of outcome in particular.
  12        I think you were describing that as being an
  13     aspiration at least to an extent at that stage, but it
  14     is fair to say that around this time similar reports, if
  15     not identical ones, were being produced by the Cardiac
  16     Services Department in the UBHT.
  17        If we look at a report for 1989 to 1990 at
  18      UBHT 55/68, this is a cover page for a report produced
  19     by the BRI and the Royal Hospital, an annual report,
  20     1989 to 1990. Let us look at page 80, where we have
  21     a report not in terms of 30 day mortality but a simple
  22     tabulation of numbers of procedures and deaths.
  23        Is that a document you had seen before today?
  24   A. No.
  25   Q. It is right to say, I think, that your statement does

   1     not comment in detail with the response to the medical
   2     audit parts of the contracts that we have seen, and in
   3     particular, any reports that may have been made by the
   4     UBHT in response to those contractual requirements.
   5        Is that something that you are able to deal with,
   6     notwithstanding that, or is that something that we
   7     should direct our questions to someone else?
   8   A. I think that this is an area which will be dealt with by
   9     my colleagues from the public health department, and
  10     I understand that you are to receive statements from our
  11     Director of Public Health, Dr Keiran Morgan and the
  12     consultant who dealt with this specialty, Dr Baker.
  13   Q. I am grateful, thank you. Can you perhaps just help
  14     us by clarifying what, as the Director of Contracting,
  15     your understanding would have been of the reporting
  16     structure or mechanisms whereby this sort of information
  17     was passed to the Health Authority, and who it went to?
  18   A. If it had come from the Trust, it would be passed to our
  19     Director of Public Health and I would have known of its
  20     existence but would not have obviously dealt with the
  21     analysis of it.
  22        If it had come from outside, it would probably
  23     have come to our Chief Executive, or possibly directly
  24     to the Director of Public Health.
  25   Q. Thank you very much. So if we can then just turn back

   1     to the contract again, that is HA(A) 11/249, we have
   2     dealt there with medical audit, and then do similar
   3     comments apply to nursing audit, or was that something
   4     you had a little bit more involvement in?
   5   A. Nursing audit was also being developed at the time and
   6     I think in the comments in section 3 of my statement,
   7     where I deal with the UBHT's monitoring returns, the
   8     Cardiac Services Directorate describe a number of the
   9     nursing audits that they have undertaken in their report
  10     to us.
  11   Q. I think in fact you have provided at least one of them,
  12     the audit of the cardiac theatres?
  13   A. That is right.
  14   Q. If we turn over the page, then, to page 250, there is,
  15     set out there under the heading of "Referral and
  16     out-patients", a very detailed series of monitoring
  17     requirements that were to be met by the UBHT. We cannot
  18     see them all, but if one scrolls through, one can see
  19     that a number of specific burdens were placed upon the
  20     UBHT there.
  21        Does that contrast between the rather less
  22     detailed standard of medical audit and the very specific
  23     requirements for reporting structures in the process
  24     measures there of outpatients waiting times reflect the
  25     extent to which information was available?

   1   A. I think it reflects two things. One is that we were
   2     in dialogue with general practitioners and they were
   3     commenting on draft service specifications and giving us
   4     their views on issues like standards of communications
   5     with GPs, say, after an outpatient attendance or after
   6     a patient had been discharged. So what we were trying
   7     to do in part was to reflect GPs' concerns round some of
   8     the process issues, and of course a number of the
   9     process standards we talk about here foreshadow the
  10     Patient's Charter which I think was formally introduced
  11     in 1992.
  12   Q. We will come on to the actual reports back from the UBHT
  13     made under these or similar requirements in a moment,
  14     but before we do that, perhaps we could go back to the
  15     subject of the extra-contractual referrals which was
  16     referred to at paragraph 10 of this contract, page 248.
  17        That describes the case of a cardiologists who
  18     might wish perhaps to refer outside the UBHT, but can
  19     you help us firstly as to the mechanism or the
  20     procedures that might have to be followed by
  21     a paediatrician who, outside the UBHT, had referred to
  22     him a child over the age of 1 who required the services
  23     either of a paediatric cardiologist or possibly more
  24     rarely a cardiac surgeon?
  25   A. Yes. I am assuming that this would be a paediatrician

   1     at Southmead, if we are talking about children resident
   2     in Bristol & Weston, or a paediatrician at the
   3     Children's Hospital, and they would simply refer on to
   4     their cardiological colleague and ask them to consider
   5     the child's case. That would all come within our block
   6     contracts with the UBHT and would not require any
   7     separate exchange of paperwork or any separate
   8     processes.
   9   Q. Yes, I am sorry, I am not making the question clear.
  10     If one takes the case of a paediatrician who has an
  11     over 1 at Southmead who, for some reason, that
  12     paediatrician wishes to refer outside the UBHT or
  13     outside the district: one can take perhaps
  14     a non-contentious example, perhaps it is a child who has
  15     just moved into the region and has already been
  16     receiving care at another centre and it is thought there
  17     might be good reasons for having continuity of care.
  18        What mechanisms would apply to allow the
  19     paediatrician to make that referral?
  20   A. I am sorry, I understand now. I think the national
  21     process changed during the period and I think in the
  22     first part of the period, for tertiary referrals, the
  23     referring clinician, in other words, the cardiologist,
  24     would have to get in touch with the Health Authority
  25     before making a referral and ask for permission for that

   1     referral to be funded.
   2        That changed with effect from 1st April 1993, and
   3     there was national guidance on this subject, so that
   4     referers no longer had to obtain prior authorisation
   5     from the Health Authority.
   6   Q. What would be the implications from the Health
   7     Authority's point of view of that referral being made by
   8     the paediatrician?
   9   A. In the specialty, the number of referrals outside, to
  10     the best of my knowledge, was very small, by which
  11     I mean, a handful of children each year. That level of
  12     referral was not one which would cause the Health
  13     Authority undue concern.
  14   Q. It is implicit in your answer, is it, that if the
  15     referral is made outside the district, the Health
  16     Authority has to pick up the bill, does it?
  17   A. It does, and it had a separate budget called an
  18     "extra-contractual referral budget" from which it met
  19     those costs.
  20   Q. So whether or not we are talking about the period before
  21     or after the paediatrician had to get permission from
  22     the Health Authority to make the ECR, would the district
  23     authority, the Health Authority, have taken steps to
  24     monitor the level of ECRs because of the bill that it
  25     might have to face at the other end?

   1   A. Yes. We had a general monitoring system for
   2     extra-contractual referrals and as time went by, we had
   3     individual scrutiny of all tertiary referrals which were
   4     undertaken by consultants in our public health medicine
   5     department.
   6   Q. Was that individual scrutiny before or after the
   7     referral had taken place?
   8   A. The guidance which changed the system with effect from
   9     1st April 1993 essentially said that although accepting
  10     hospitals did not need to seek prior authorisation for
  11     a tertiary referral, nevertheless the referring
  12     clinician should inform the Health Authority before
  13     making the referral, and at that point, a dialogue could
  14     take place.
  15   Q. If we take the example now not of a paediatrician at
  16     Southmead, but supposing we are dealing instead with
  17     a paediatric cardiologist at the BCH, who again, for,
  18     let us suppose, non-contentious reasons has a child with
  19     an established relationship with a surgeon in another
  20     region and wishes therefore to refer the child to that
  21     surgeon rather than to the BRI, would the same
  22     procedures apply to him in making that choice?
  23   A. The same procedures would apply, and it was recognised
  24     by the Health Authority that one of the reasons for
  25     making tertiary extra-contractual referrals might indeed

   1     be to preserve the continuity of care of a patient who
   2     had been treated previously at another place.
   3   Q. What about the funding implications for the UBHT if an
   4     ECR was made by a paediatric cardiologist at the BCH,
   5     would there be any funding knock-on effects for the
   6     hospital?
   7   A. No. There was no detriment to the UBHT from one of
   8     their clinicians making an extra-contractual referral.
   9   Q. That follows from the "block contract" system that you
  10     described earlier?
  11   A. Indeed.
  12   Q. Unless, perhaps, if I put this example, the numbers of
  13     those referrals reached such a level that they would
  14     call into question the numbers of cases that were going
  15     through the hospital and therefore the funding for next
  16     year's contract?
  17   A. Yes. That is the case.
  18   Q. That is the case, but you mean that is a theoretical
  19     possibility, or an actual possibility or probability
  20     that occurred?
  21   A. I cannot think of exactly that situation happening in
  22     the Health Authority, but we did face a situation,
  23     actually after the Inquiry's period, when we had
  24     a fairly small number of mental health referrals of very
  25     complex cases where individuals required long-term care,

   1     where there was no equivalent provision within the
   2     district. So this did become a very big issue and it
   3     was certainly one on which there was tremendous dialogue
   4     between the Health Authority and the referring
   5     consultants.
   6   Q. If we turn back to cardiac services and the actual
   7     number of extra-contractual referrals that were being
   8     made in this field in the district, you provided to your
   9     statement some tables that I think had been calculated
  10     by a colleague of yours, Mr Prothero; is that right?
  11   A. Yes.
  12   Q. If we turn to page 115 of your statement first, that
  13     is the discussion on tables 5, 6, 7 and 8, which we will
  14     go to in a moment from Mr Prothero. We see his
  15     signature down the page. He makes it clear there, if we
  16     go back up the page, that this data was transferred or
  17     supplied to the Health Authority from the Mersey
  18     Regional Health Authority.
  19        I would like you, if you would, to comment on the
  20     nature of this data in a moment, but perhaps for the
  21     sake of completeness we should go to the tables first.
  22     If we look at page 301; we see there, is this right,
  23     that we are looking at children aged 16 and under who
  24     were referred in the specialty of cardiac surgery
  25     outside of the authority, firstly in the years 1989 to

   1     1990, and the figures appear to show zero. If we scroll
   2     down the page, those are the three health authorities
   3     that still existed in that year.
   4        If we turn over, page 302, we get similar figures
   5     for 1990 to 1991. Then, if we turn over to 1991/92, now
   6     we are just looking at the one health authority. It
   7     would appear that numbers have jumped and that from zero
   8     we are, for the first time, seeing a total of 14
   9     referrals outside of the authority for children aged
  10     1 to 16.
  11        If we could just look at 1992/93, the figure
  12     is 19. 1993/94, 15. Finally, over the page, a total
  13     of 7.
  14        If one merely looks at those tables, it appears
  15     there is a change in the pattern from after 1991. Are
  16     you able to help us further on the accuracy or reliance
  17     that can be put on that data?
  18   A. Yes. We need to draw a distinction between data
  19     relating to children treated outside the authority,
  20     which went through a clearing system run for the
  21     country, Mersey Regional Health Authority and our own
  22     data on individuals treated within the Health Authority
  23     which we could draw direct from the hospital computer
  24     systems.
  25        The data which came to us via Mersey Regional

   1     Health Authority was less robust, and that was due in
   2     part, I think, to the fact that the submission of that
   3     data was not mandatory. In general terms, if it is
   4     mandatory to submit data, then data quality tends to be
   5     better. In this particular case, I think we looked
   6     further into the referrals that are shown in this table
   7     and I think we find two things. One is that at the top
   8     of the table you can see that the activity is counted in
   9     what is shown as being FCEs, that means finished
  10     consultant episodes, and in fact relates to a much
  11     smaller number of children having repeat admissions,
  12     particularly in the early years in which we saw the
  13     higher numbers.
  14        So that is one recording issue. But the second
  15     one is that on further analysis we found that for 91 to
  16     23 and 34, where we see the higher figures, that is
  17     actually due to data being submitted by Great Ormond
  18     Street Hospital which was coded under the specialty of
  19     cardiac surgery but which we have very recently
  20     interrogated at individual patient level, and the
  21     majority of the cases shown relate in fact to cystic
  22     fibrosis treatments.
  23   Q. I think you have actually supplied now an addendum to
  24     table 5 which makes that point, that what has been
  25     classified as cardiac surgery in this relates to cystic

   1     fibrosis, and makes a further point that no data had
   2     been provided to the Mersey clearing station by Great
   3     Ormond Street in 1989/90, and 1990/91, so that when the
   4     figures are shown as zero in the earlier part of the
   5     table, that appears to be a product of the failure to
   6     transmit information to Mersey rather than a pattern of
   7     referral; is that correct?
   8   A. That is right.
   9   Q. It may be we can scan that addendum into the statement
  10     and add it as an addition to your statement, if you are
  11     content with that?
  12   A. Yes.
  13   Q. If one turns instead to UBHT 12/209, we can see there
  14     a discussion -- it is a late discussion under the
  15     heading of "Avon Health" dated March 1995, but there is
  16     a general discussion there of tertiary extra-contractual
  17     referrals. If we can just scan through that briefly,
  18     there is a discussion of the nature of the referrals
  19     first, and then, towards the bottom of the page, an
  20     analysis of tertiary ECRs. If one turns over the page,
  21     we see an analysis of the ones that have caused concern
  22     or expenditure, and if we can scroll through that,
  23     please, and turn over the page, we can see there
  24     paragraph 3.1, the summary that the major increase in
  25     tertiary ECR costs arise in mental illness.

   1        Does that reflect what you were saying to the
   2     Inquiry a little earlier?
   3   A. Yes, indeed.
   4   Q. I think it is right that this document does not reflect
   5     any concern over the numbers of referrals in paediatric
   6     cardiac surgery or cardiology; is that right?
   7   A. That is correct.
   8   Q. In general, was there any reason for the authority to
   9     pick up from the level of referrals in paediatric
  10     cardiac surgery or cardiology any reason to suppose
  11     there was any issue relating to those referrals?
  12   A. No. The numbers of referrals which we processed through
  13     our extra-contractual referral system were very small
  14     indeed.
  15   Q. If we can turn back, then, to the contractual
  16     documentation you supplied, at page 48 of your
  17     statement -- I really highlight this for the sake of the
  18     record -- you supplied us with a summary of the
  19     development of the service contracts that were made by
  20     the Health Authority throughout the term, the period of
  21     our Inquiry.
  22        In particular, we can see, is this right, under
  23     the heading of "Quality and clinical audit" that as the
  24     years went through, the specifications for children
  25     became more exact as you began to refer to national

   1     standards produced either by the National Association
   2     for the Welfare of Children in Hospitals or by the
   3     Department of Health?
   4   A. Yes, that is right.
   5   Q. What monitoring went on to ensure that those standards
   6     were met in reality?
   7   A. We received monitoring from each Trust and these
   8     standards, it would normally be 6 monthly monitoring,
   9     where the Trust would report on compliance with our
  10     standards and any additional activity that they were
  11     undertaking. So the relevant reports as far as the
  12     Inquiry is concerned would be from the children's
  13     directorate, the Children's Hospital, at the UBHT and
  14     from the cardiac surgery directorate.
  15        I think in my statement I have mentioned a number
  16     of reports which relate either to nursing audit and
  17     auditing aspects of the service for children, or to the
  18     patients' surveys which took place both in the cardiac
  19     surgery ward and in the Children's Hospital, and which
  20     sought parent and sometimes children's opinion on
  21     various aspects of the service.
  22        So there were a number of ways in which we tried
  23     to check that the Trusts were being active in this
  24     area.
  25   Q. If we go back to your statement at page 13, we can see

   1     there, in paragraph 2.1.17, the fact that every year the
   2     Health Authority was setting out its purchasing
   3     intentions for the year and that that set out the
   4     spending priorities and issues that were regarded as
   5     being particularly important throughout the year.
   6        Did children's services raise any particular
   7     concerns or problems for the Health Authority?
   8   A. That is a question with many parts, really. I think
   9     that over the period of the Inquiry -- over the period
  10     from 1991 to 1995, there were issues relating to
  11     community child health services, community based
  12     services, and I recall, towards the end of the period,
  13     that the Community Health Council produced a report on
  14     that area which I think was fairly critical.
  15        In more recent years, the Health Authority has
  16     undertaken a major piece of work with Trusts and
  17     colleagues from the local authorities about reviewing
  18     community child health services.
  19        Child and adolescent mental health services were
  20     an issue during the period and some aspects of acute
  21     services for children were an issue, for example, the
  22     growing number of bone marrow transplants which were
  23     undertaken for children each year, so, yes, children's
  24     issues did feature, and they featured across the board.
  25   Q. If we turn specifically to the area of cardiac services,

   1     and we are looking at page 15 of your statement,
   2     paragraph 2.2.5, the emphasis there, and I think
   3     throughout your evidence in the statement, is that for
   4     the over 1s to the age 16s there were no particular
   5     concerns or issues identified by the Health Authority
   6     during the period 1991 to 1995?
   7   A. I think one which is worthy of note and which we
   8     consulted on publicly in our purchasing intentions
   9     document was the issue about integrated management of
  10     services, paediatric cardiac services, and by that what
  11     we were interested in was that there was I think
  12     a degree of overlap between the cardiological treatment
  13     and surgical treatment for children with certain heart
  14     conditions. We felt that it might be appropriate for
  15     that clinical overlap and the joint discussions which
  16     happened between the cardiologists and the cardiac
  17     surgeons about treatment patterns to be reflected in an
  18     integrated management arrangement for children with
  19     heart problems.
  20   Q. I think you have set out in the statement the chronology
  21     or the events relating to developing that integrated
  22     approach.
  23        Can you recollect when that became an issue for
  24     the Health Authority?
  25   A. As it was, as our interest was stemming from a clinical

   1     issue I think that might be a question which my
   2     colleague Dr Baker can help you with in more detail.
   3   Q. Thank you. Returning then to paragraph 2.2.5, you say
   4     there that there were no significant rating times for
   5     children. Were they monitored separately, or is that
   6     a comment that you make because of knowledge of GP
   7     feedback on the subject?
   8   A. We were able to monitor directly all waiting times in
   9     the acute specialties, both for outpatients and for
  10     inpatients, so, yes, we could look at those directly and
  11     if GPs had concerns about waiting times in a specialty,
  12     then there were many fora in which we had debate and
  13     discussion with GPs and in which they raised their
  14     concerns. Paediatric cardiology and cardiac surgery was
  15     not one where waiting times were in issue, nor was it
  16     one where GPs raised waiting times with us.
  17   Q. I think what I was asking by way of the question on the
  18     information you had available was not whether you had
  19     access to information on waiting times, but whether it
  20     was separately broken down for adults and children?
  21   A. Yes, it was separately broken down for adults and
  22     children.
  23   Q. So if we go on, then, we can see you have set out,
  24     throughout this part of the statement, the general
  25     concerns and priorities and initiatives in relation to

   1     adult cardiac services. We will not turn to it, but
   2     Appendix 9 lists the waiting list initiatives in this
   3     area. You have also given us the details in the
   4     increasing numbers of adult contracts.
   5        Equally well, you make the point that considerable
   6     work was done by the district on the question of
   7     equality of access for adults to cardiological services.
   8        Was this something that was ever raised in
   9     relation to children and their access to cardiological
  10     services throughout the district?
  11   A. Not to my knowledge.
  12   Q. So it was not raised in particular by GPs in your
  13     feedback with them?
  14   A. No.
  15   Q. Again, there is a lot of information relating to adult
  16     cardiac services and in particular, if we look at the
  17     regional review produced in 1992 by the Health
  18     Authority, that is to be found at HA(A) 11/69.
  19        There we see subsequently the scope of the RHA's
  20     work. If we go scroll down the page, and over the page,
  21     please, the detailed comments should be available. Then
  22     the proposals, we are looking there at supply options,
  23     and in particular, proposals being invited from the UBHT
  24     and various other providers.
  25        The comment there is on cost, that out-of-region

   1     providers appear to be able to provide additional
   2     volumes at less cost than either the UBHT or a new unit.
   3        If one goes down the page to "Clear conclusions
   4     about quality", there it says that there are a number of
   5     anecdotal comments indicating unhappiness on the part of
   6     the local GP and cardiologists about the way the service
   7     operates at the UBHT. "Duplication of tests locally and
   8     poor communication."
   9        Was that something that you found to be a problem
  10     and were working on, or is that an isolated finding?
  11   A. I think that the issue about duplication of tests was
  12     one where a GP or a cardiologist in a more distant
  13     health authority, such as Exeter or Gloucester, would
  14     undertake tests and then, when the patient was referred
  15     to UBHT, the tests would be done again. That situation
  16     was not an issue within the district because the tests
  17     were being done once and did not seem to be an issue.
  18        I am not sure what that comment about "poor
  19     communication" relates to in this context.
  20   Q. If we look, then, at page 79, this is part of
  21     a follow-up to that particular report, where it says
  22     there, if we scroll down a little:
  23        "Not all provider units are currently meeting
  24     professional advice on the criteria for a viable high
  25     quality unit."

   1        Then there are standards set out about a certain
   2     number of major surgical procedures, number of surgeons
   3     and the workload for each surgeon and the letter then
   4     asks each purchaser to ensure that all the units being
   5     used by them meet those standards.
   6        There is then a little scrawl, a little note right
   7     at the top of the page:
   8        "Debbie Evans, Ian Baker, we seem to be in the
   9     clear", which seems to mean that for the UBHT the
  10     standards were met.
  11        Is that a fair interpretation of that particular
  12     note?
  13   A. I do not know. The comment was written by the Chief
  14     Executive of the Health Authority, and I do not know
  15     whether he had actually checked that the performance
  16     criteria set out were met by UBHT. I do not think, at
  17     that point, they were already doing 700 procedures,
  18     although I think that growth was anticipated that would
  19     take them to that level.
  20   Q. But the point is that there is there set out a series of
  21     standards and the units are being monitored against that
  22     standard. In relation to children, again looking at the
  23     over 1s to the 16s, were you aware of any similar
  24     standards that were being applied against which you
  25     could check the UBHT's performance to see whether or not

   1     there was an adequate throughput, adequate number of
   2     surgeons, adequate number of cases being performed by
   3     each surgeon?
   4   A. I am not aware of the existence of those standards
   5     myself. I am sure that it would be appropriate to ask
   6     public health colleagues about the evidence base and any
   7     published standards which existed at that time.
   8   Q. But I think from your role as Director of Contracting,
   9     you ought to be able to say whether any such review was
  10     in fact carried out by the Health Authority. If it was
  11     not, it may well be because those standards did not
  12     exist, but can you tell us whether or not those checks
  13     were taking place?
  14   A. I do not think there was a review of that sort for
  15     children over 1 between 1991 and 1995. My feeling is
  16     that the evidence base may not have existed, but I think
  17     that is an issue to put to my colleague.
  18   Q. Thank you. If we could turn to monitoring in a bit more
  19     detail, you mention it at paragraph 3.1.4 of your
  20     witness statement, page 27, where you talk about the
  21     Health Authority's quality specification and its
  22     capacity to monitor all aspects of service quality.
  23     Then you say that health authorities were encouraged not
  24     to attempt to monitor details of provider management of
  25     quality. Then the reference is set out.

   1        If we could look, perhaps, at page 168, I think as
   2     part of those guidelines, we see there the guidance in
   3     the third bullet point there, that although details of
   4     provider management of quality should be kept to the
   5     minimum, the contract must cover any express national
   6     requirements, e.g. Patient Charter standards, and also,
   7     above that, contracts must include details of agreed
   8     effective means of monitoring quality specifications.
   9        Before we discuss that, perhaps we could look at
  10     page 181 of that document. Where, at the very bottom of
  11     the page -- it is part of a discussion of contract
  12     negotiation disputes -- it says:
  13        "It is important that local agreements included in
  14     contracts are sensible and achievable ... avoiding
  15     unrealistic expectations about pace of change and the
  16     need for robust but minimal monitoring arrangements."
  17        Can you help us as to the philosophy or approach
  18     that lay behind this guidance or advice to health
  19     authorities on the nature of the monitoring that they
  20     should be undertaking of Trusts?
  21   A. Can you just remind me what year we are talking about?
  22   Q. Yes, I am sorry. Could we go back to page 166,
  23     please, where the headline is, the first page of the
  24     document.
  25   A. Yes, thank you. I think that by this time, by 1994/95,

   1     Regional Health Authorities were getting feedback from
   2     some Trusts across the country that they were finding it
   3     difficult to meet with all the purchasers' quality
   4     requirements.
   5        One of the issues was that different purchasers
   6     would want to make different quality requirements of the
   7     same Trust, and one can imagine that with a Trust like
   8     UBHT with 43 purchasers, that would have been difficult.
   9        GP fundholders also, on occasion, wanted to agree
  10     separate arrangements again, and I think that the advice
  11     that we are reviewing here is a reflection of messages
  12     which were, by then, coming through to purchasers, both
  13     from the NHS Executive and from regions, that quality
  14     monitoring of requirements should be minimal.
  15   Q. Can you then help us as to the breakdown in
  16     responsibility, then, for first ensuring quality between
  17     the Trust and the District Health Authority?
  18   A. It was the Trust's responsibility to make sure that it
  19     had appropriate frameworks and processes in place for
  20     quality assurance, both in terms of clinical audit and
  21     in terms of what perhaps might be described as
  22     "processes of care".
  23        In addition to that requirement, health
  24     authorities had specifically laid upon them certain
  25     national requirements, many of which came under the

   1     Patient's Charter, and these were requirements that we
   2     should monitor certain aspects of patient care
   3     processes, notably waiting times in Accident and
   4     Emergency departments, waiting times in outpatient
   5     clinics, between patient arrival and seeing
   6     a consultant, cancellation of operations, and, of
   7     course, waiting times for inpatient and outpatient
   8     appointment from GP referral.
   9   Q. What about the standards of care, the outcomes of care?
  10     What, if any, role did the Health Authority have in
  11     monitoring those?
  12   A. I think the primary responsibility was laid on Trusts
  13     and their reporting was through the Region to the
  14     Centre. I think the Health Authority had a role, and
  15     I think a recognition of the Health Authority's role
  16     evolved over time, so that, by I think about 1995, it
  17     was recognised -- and in that encouraged -- by the
  18     Department of Health that health authorities should have
  19     the right to nominate certain audit topics that Trusts
  20     would undertake. But that was very much towards the end
  21     of the period and I think we saw our role as being to
  22     encourage the development of audit and to work with our
  23     Trusts, all of our Trusts, on specific audit topics,
  24     particularly those which, like the work we did on heart
  25     attacks, seemed to be important in terms of illness

   1     within our population, and health care for our
   2     population.
   3   Q. You say that the authority had a role, but what, if we
   4     take it back to the beginning of our period, 1991, when
   5     you first became involved as the Director of
   6     Contracting, did you understand was the scope of that
   7     role at that time?
   8   A. I think that it was our role to satisfy ourselves that
   9     audit was taking place.
  10   Q. Was that a question of looking at structures, processes,
  11     or at the outcomes themselves?
  12   A. I think it was particularly making sure that audit
  13     processes were taking place. The responsibility for
  14     audit that was laid on the Trusts required that Trusts
  15     produced an annual audit report and that annual audit
  16     report was shared with health authorities.
  17        For most of the period, funding for audit came
  18     direct from the Department to Trusts, and I think
  19     latterly, it came from the Department through the
  20     regional Trusts, but not through the health
  21     authorities. I think that is symbolic of the role that
  22     health authorities were seen as playing in audit at that
  23     time.
  24   Q. Again, we will cover this in more detail with Dr Baker,
  25     but does it follow from what you have just being saying

   1     that the shift you have talked about, the development in
   2     the role was perhaps signified by the greater
   3     involvement by the Authority at the end of the period in
   4     actually choosing the audit topics or setting an agenda
   5     in partnership with the Trust for the content of that
   6     monitoring?
   7   A. I think that is right. The Health Authority was keen to
   8     see audit taking place; it recognised that it was in its
   9     infancy and that it was developing and that we had
  10     a role in encouraging audit. I think the last appendix
  11     to my statement shows a schedule for audit which we had
  12     agreed with the UBHT, I think in 1994/95, which
  13     identifies specific topics, some of those topics related
  14     to adult cardiac services, and I think that reflects our
  15     very real efforts to be engaged and to work with the
  16     Trusts, and in that instance to develop quite an
  17     ambitious audit about care of patients who had had heart
  18     attacks which involved all four of the acute Trusts and
  19     which involved staff on a multidisciplinary basis.
  20   Q. Does the perspective of the Trust and the perspective of
  21     the Health Authority on audit or outcomes or services
  22     differ in any way? Did the two perhaps legitimately
  23     have a different understanding of what they might wish
  24     to look at when looking at services and their
  25     provision?

   1   A. I think so, and I think this relates back to, you
   2     know, the Health Authority being rooted in the needs of
   3     the local population and perhaps that dictating that
   4     there might be particular areas that we were interested
   5     in, either because they were services which a large
   6     proportion of the population received, like cataract
   7     services or services for people who had had heart
   8     attacks, and of course, the Trust had a more
   9     comprehensive role, I think, as providers and managers
  10     of service in making sure that audit was happening in
  11     every specialty and for every service and perhaps
  12     including within it a role for looking at adverse events
  13     and critical events that had happened.
  14        So I think they had a rather different role than
  15     we did.
  16   Q. You seem to be describing a focus that is rather more on
  17     the public health concerns or the epidemiological
  18     aspects of the service provision, rather than upon the
  19     details of the clinical delivery or levels of service at
  20     a more detailed level?
  21   A. I think that is true. I think we were still interested
  22     in knowing that outcomes were satisfactory, and I think
  23     that was an important part of our role. But again, it
  24     is a question of expecting the Trust to be taking the
  25     comprehensive view from their end of every specialty,

   1     and we were looking at particular issues.
   2   Q. We have been talking subsequently about the cardiac
   3     services and in particular we have been talking
   4     throughout of cardiac services for the over 1s, because
   5     those were the contracts which you were managing. It is
   6     right to record that some witnesses before the
   7     Inquiry -- I am talking now of witnesses from the
   8     Department of Health or from the NHS in Wales --
   9     recorded the view that the Supra Regional Services
  10     Advisory Group of the Department of Health was not in
  11     the business of detailed regular monitoring of outcomes
  12     or clinical quality within any of the supra-regional
  13     centres and that, notwithstanding the contract between
  14     the Department of Health and the unit concerned, they
  15     regarded the provision of health care as being the
  16     responsibility or statutory responsibility of local
  17     health bodies and took from that the conclusion that the
  18     responsibility for standards in the supra-regional
  19     centres remained with local health authorities.
  20        Can you comment on that view, as to the district's
  21     responsibility, that is, for services for the under 1s?
  22   A. I did not believe that it was our responsibility to be
  23     monitoring quality of service for children under 1, as
  24     my understanding was that those services were purchased
  25     directly by the NHS Executive and therefore that body

   1     would take responsibility for monitoring clinical
   2     quality.
   3   Q. You referred in your statement to the contracts that
   4     were made between the Department of Health and the UBHT
   5     for services for the under 1s, and you note in your
   6     statement that they do provide references to some
   7     measures of outcomes or clinical standards.
   8        Are you aware of any information being passed from
   9     the Department of Health to the district that would have
  10     a bearing upon the question of quality, or might have
  11     reflected the results of any monitoring of that quality
  12     by the Department of Health?
  13   A. No, I have never seen any monitoring returns from the
  14     NHS Executive on supra-regional services, and in fact
  15     I do not know whether that draft service agreement which
  16     we submitted between the NHS Executive or the Department
  17     of Health and the UBHT for paediatric cardiac surgery
  18     ever came into effect. The draft was certainly there,
  19     but I do not know what happened in reality.
  20   Q. You were not, anyway, as Director of Contracting, copied
  21     into any correspondence between the UBHT and the
  22     Department of Health about services for the under 1s or
  23     the contracting process?
  24   A. I was not.
  25   Q. If we then go on to what you were very much part and

   1     parcel of, the question of the returns made by the UBHT
   2     on the various indices of quality or standards in the
   3     contracts you had made, you have given very detailed
   4     evidence to the Inquiry on this and summarised very
   5     helpfully what comes out of the documents. I do not
   6     want to spend time simply rehearsing what is already in
   7     the documentation, but if one looks perhaps at one or
   8     two of the things that emerge, if we look at a Health
   9     Authority document, HA(A) 43/11, there is a discussion
  10     of the contracting process in 1992/93, looking forward
  11     to it, and the relevant part of the document is at
  12     page 14 where there is a general discussion on the
  13     UBHT's overall approach to quality that year.
  14        The comment there is set out that the UBHT does
  15     not appear to have an overall approach to quality. This
  16     lack of ownership of quality is one of the UBHT's
  17     weaknesses in the field. To set against that, there is
  18     an assessment of the strengths of the UBHT. They have
  19     a very professional unit to undertake work on customer
  20     satisfaction and they talk about sound methodology for
  21     monitoring outpatient episodes.
  22        The same point about ownership of quality is
  23     actually mentioned in your statement in the documents at
  24     page 241, but I have taken you to this reference instead
  25     of that because it balances both the assessments of

   1     weaknesses but also of strengths.
   2        Are you able to help us further on the point made
   3     there about lack of ownership of quality or the lack of
   4     an overall approach to quality?
   5   A. I think that in 1990/91/92, which this report is
   6     relating to, both the Trusts and ourselves as purchasers
   7     were feeling their way in this new world of different
   8     responsibilities for quality assurance.
   9        Certainly, the comment at 5.2 about the overall
  10     approach was also one which I made to them in my
  11     feedback following their first set of monitoring
  12     returns.
  13        The UBHT later established a committee which was
  14     chaired by one of their non-executives, which was
  15     deliberately -- I think that one was aimed at looking at
  16     marketing issues and so on, but it was certainly
  17     a committee which sought out feedback about UBHT
  18     services. I was invited to that. I think latterly the
  19     Trust also developed a committee which was specifically
  20     about looking at quality. So it was an issue which
  21     I think they recognised and addressed over time,
  22     although, at this point, I think our comment was valid.
  23   Q. How did the Trust's initial difficulties, as you have
  24     just described them, compare to those being experienced
  25     by other Trusts in the district at that time?

   1   A. I think that all Trusts were addressing their new role
   2     and having some difficulties with them. I think, if
   3     I remember rightly, that UBHT was fairly good at
   4     producing monitoring returns compared to some of the
   5     Trusts, so we had fuller and more comprehensive returns
   6     from some Trusts, including UBHT, than others. I do not
   7     think it was uncommon. I do not think that many Trusts
   8     at this early stage really had an overall approach to
   9     quality assurance.
  10   Q. You have just suggested that the Trust did take steps to
  11     address this, but can I just press you a little further
  12     on how much change had resulted by the end of our
  13     period?
  14        If we look at page 190 of your witness statement,
  15     there is a letter there which is written by you. It is
  16     your signature and your name is on the second page, but
  17     if we just stay on the first page for a moment, you are
  18     reporting back on the monitoring report, October 1993 to
  19     1994, and you comment there that the report was well
  20     focused and comprehensive, but "there is still
  21     insufficient evidence of managers 'owning' results and
  22     taking follow-up action."
  23   A. From our point of view, one of the key things we would
  24     look at from one set of monitoring returns to the next
  25     would be to see whether the areas which had been

   1     identified as problems had been addressed by managers
   2     and followed up. I think it was always the case that we
   3     were very alive to instances where this had not
   4     happened.
   5   Q. Again, how would you compare those difficulties or the
   6     continuing need for work and emphasis on that area with
   7     your experience of dealing with other Trusts in the
   8     district?
   9   A. I think it applied to all Trusts, and I think in some
  10     cases it relates to, it takes some time to put problems
  11     right when you have identified them. So, for example,
  12     if you find there are problems in your patient discharge
  13     process, that is quite a complex process to re-engineer
  14     and may take more than 6 months or a year to do. So
  15     I think it was an issue which applied to all Trusts.
  16   Q. If we look at the document from the Health Authority
  17     again, HA(A) 7/33, this examines a general theme,
  18     perhaps, throughout some of our period which is the
  19     general intention or aspiration to move from looking at
  20     items of process to looking at standards of outcome.
  21        If we go through it a little bit, it is a little
  22     difficult to see all of it. One is looking towards the
  23     bottom of the paragraph at the monitoring for 1991 to
  24     1992, and then, if we turn over the page, one can see
  25     there a general discussion, towards the bottom of the

   1     page, in particular on reviewing the appropriateness of
   2     quality measures.
   3        There the comment is set out that targets and
   4     quality measures were largely speculative and it was
   5     important to try and establish what the most useful and
   6     appropriate measures of quality were and how to evaluate
   7     them. Research was being done in the country, across
   8     the area.
   9        Can you help us a little bit as to the nature of
  10     the debate that was being carried on there and the
  11     extent of the progress that you were able to make
  12     towards this as a commissioner throughout the period
  13     from 1991 to 1995?
  14   A. Are you thinking specifically about outcome
  15     measurement?
  16   Q. Yes, in cardiac surgery in particular.
  17   A. I think that, again, this is an area which you will want
  18     to ask my public health colleagues about, but I think
  19     that, certainly from 1992/93 onwards, there was work
  20     under way within the UBHT from the cardiac surgeons
  21     looking at mortality rates following coronary artery
  22     bypass grafting, and one of the difficult issues that
  23     I think they were trying to address was the issue of
  24     whether they were comparing like with like and whether
  25     they had standardised the inputs to allow them to make

   1     those comparisons.
   2        So that work went on from 1992/93 onwards, and we
   3     had some involvement and some dialogue with them on it.
   4        On the cardiological side, from 1993/94, certainly
   5     through 1994/95 and I think into 1995/96, we were
   6     engaged with the cardiologists from all the hospitals on
   7     a big audit of the use of thrombolytic therapy, which is
   8     clot-busting therapy, for people who had had heart
   9     attacks.
  10        We led that piece of work ourselves and we
  11     negotiated an acceptable methodology with the
  12     cardiologists at all sites and we had Working Groups
  13     involving, for example, nurses from the Accident and
  14     Emergency departments and the coronary care units and so
  15     on. So that is a very big piece of work which
  16     demonstrated that we were collectively looking at
  17     outcomes in a fairly sophisticated way, I think.
  18   Q. I will not, I think, take you through the references
  19     that you have given to the process of monitoring and the
  20     dialogue between the UBHT and the Health Authority on
  21     the monitoring of standards, but I think that, reading
  22     those documents, it does appear that there was indeed
  23     a dialogue and there is quite a constant process of
  24     reporting feedback, feedback on feedback, and that being
  25     fed through into the next report.

   1        Is that a fair summary or an over- or
   2     under-optimistic view of the process you have described
   3     in your statement?
   4   A. I think we were very active in quality monitoring.
   5     I think probably that if one were to look at other
   6     district health authorities we were at least as active
   7     as others and probably more active than some. I think
   8     in my statement I was also trying to demonstrate that
   9     through the iterative process, we were identifying
  10     shortcomings and within the UBHT's directorates, they
  11     were trying to put them right. I think that is what one
  12     would expect to see in any cycle of quality monitoring,
  13     that you try and establish your standards and then check
  14     performance against them and if you feel they are not
  15     good enough, then you take corrective action and go back
  16     and re-audit them.
  17        I think we could see that taking place. That is
  18     certainly the cycle that we were hoping to establish,
  19     and did establish in the thrombolytic therapy audit on
  20     the clinical outcome side.
  21   Q. To summarise the position that the District Health
  22     Authority was able to achieve, if one turns back to the
  23     Audit Commission report we have looked at before,
  24     WIT 46/451, in the context here towards the bottom of
  25     the page, please, of specialised services, the Audit

   1     Commission was looking at four key questions which it
   2     suggests the local authority should be asking itself.
   3     Can I ask you how you would rate your own department's
   4     performance on these four indicators, looking at cardiac
   5     services for which you were responsible over 1991/95?
   6   A. I think these questions encompass the whole of what the
   7     Health Authority was trying to do and not just my
   8     department. So taking them from the top, the first
   9     question, "Do authorities know if the right patients are
  10     receiving the right care?", the Audit Commission talk
  11     about needing good information on the needs of their
  12     population and I think for cardiac services we regularly
  13     reviewed the needs of our population. That was
  14     reflected in the five year investment plan that we had
  15     for secondary care cardiac services.
  16        I think that the second part of that, about
  17     whether patients are receiving the right care, is about
  18     needing good information on effectiveness and
  19     cost-effectiveness of treatments and the circumstances
  20     in which treatments work.
  21        I think we were very much part of that debate for
  22     cardiac services. As far as children were concerned,
  23     there is the discussion that I alluded to about the
  24     overlap between cardiological investigation and
  25     treatment and surgery, in which circumstances it would

   1     be best and of course on the adult side, there was
   2     really a very long-running debate between ourselves, the
   3     cardiologists and the cardiac surgeons about the balance
   4     between different treatments, such as angioplasty as
   5     against coronary artery bypass grafting and in which
   6     circumstances it would be most appropriate. So we were
   7     certainly active on point 1.
   8        Point 2, "Do health authorities know what they are
   9     buying", I think is a very difficult one. I think it
  10     was acknowledged that the issue about pricing for
  11     particular procedures was fraught with difficulties.
  12     I do not think that our Health Authority was in any
  13     better or worse position to make judgments on this than
  14     other health authorities. I would like to just refer
  15     you to another Audit Commission report which was the one
  16     that they did about commissioning services for the
  17     treatment of coronary heart disease, which they
  18     published in 1995.
  19   Q. I think, just to interrupt you there, we have it
  20     available on the database. If the technology works it
  21     should be at WIT 46/231.
  22        If you want to now address your comments to
  23     that --
  24   A. It is perfect. This is looking at coronary artery
  25     bypass grafting operations just as one simple example.

   1     It shows five sites and between those five sites -- none
   2     of which incidentally includes Bristol, it is not in
   3     this sample -- these five sites have nine prices for
   4     coronary artery bypass grafting. If you look at the
   5     notes down the side, you can see how difficult the
   6     comparisons are, because some rely on the patient only
   7     staying in intensive care for 48 hours or the price
   8     changes. The length-of-stay price is readjusted after
   9     17 and 30 days, and so on.
  10        So the short answer is, there was no
  11     standardisation in Health Service pricing for
  12     procedures.
  13   Q. Just to interrupt for a second, you do not actually need
  14     to lean forward into the microphone, it will pick you up
  15     even from sitting back.
  16        Was that something that affected your contracting
  17     for cardiac services specifically, or ...
  18   A. I think it was something that we bore in mind when there
  19     were discussions about whether procedures were cheaper
  20     elsewhere, and of course, the UBHT price for coronary
  21     artery bypass grafting falls well within this
  22     considerable range shown here.
  23   Q. We have gone away from the four questions that were
  24     listed at page 451. If we go back to that, perhaps, you
  25     were addressing the issue of whether health authorities

   1     knew what they were buying.
   2   A. Yes, and perhaps, really, I have been talking more about
   3     the value-for-money question, so, to go back into health
   4     authorities and what they are buying, I think this is
   5     all to do with information and whether health services
   6     have access to good information. I think we have
   7     probably covered this fairly well already in our
   8     conversation this morning, but I think that our Health
   9     Authority and health authorities in the South West
  10     region had good information about hospital services and
  11     that would include cardiac services and it would include
  12     an analysis of all the different procedures that
  13     patients were having, whether they were emergency or
  14     routine admissions, and so on, so I think we did have
  15     a pretty good picture of what we were buying.
  16   Q. What about the question of judging whether the services
  17     were good?
  18   A. I think that the answer to this is a bit complicated,
  19     and I think that this Audit Commission report itself
  20     rehearses the arguments about judging whether services
  21     are good, in talking about the difficulties in comparing
  22     like with like; in talking about the difficulties of
  23     measuring outcomes in some cases; and, I think
  24     importantly, in registering that sometimes, even if you
  25     can measure the outcome, it is not necessarily easy to

   1     identify which part of the process of care is affecting
   2     the outcome.
   3        So I think those were the limitations and they
   4     applied to us as well as to other health authorities,
   5     and within those limitations over the period I think we
   6     were active in terms of clinical outcomes in trying to
   7     look at selected services and I think in terms of the
   8     process stuff, I think we were very active.
   9   Q. Can I just raise one further matter with you,
  10     Miss Evans? The contracts we have been looking at were
  11     really contracts supporting what you might call the
  12     "revenue" side of the UBHT's operations?
  13   A. Yes.
  14   Q. What provision or assistance might be afforded by the
  15     Health Authority if the Trust required capital
  16     investment in order to further support an area of its
  17     activity? Now clearly a move to the Clinical Directors
  18     would be one example, but there would be other lesser
  19     examples of the refurbishment of a ward or a theatre and
  20     so on, where it might be difficult to find the money out
  21     of on going revenue contracts.
  22        What were the mechanisms for supporting that form
  23     of development?
  24   A. Trusts had access to capital directly from the centre
  25     via the regions, and one of the changes that happened in

   1     1991 was that health authorities no longer had the right
   2     to approve or not approve requests for capital from
   3     Trusts.
   4        However, as a result of a system called "capital
   5     charges", there was a cost, a revenue cost, attached to
   6     new buildings, major new equipment. So it was with
   7     regard to those issues that health authorities would be
   8     drawn into discussions.
   9        So, typically, the capital charges revenue element
  10     on a new building would be about 10 per cent of the
  11     value of the capital.
  12        So we were involved in discussions of that type.
  13     Generally with the very big Trusts, like UBHT, we would
  14     expect them to handle the revenue consequences of
  15     changes in their capital stock themselves, because they
  16     had so much capital stock which was constantly, as
  17     a matter of national policy, being revalued, some
  18     elements of it would decrease and therefore our revenue
  19     funding would decrease and others would increase. We
  20     generally speaking expected them to balance those two
  21     things off.
  22   MISS GREY: Thank you very much. It may be that the Panel
  23     have some questions for you.
  24   THE CHAIRMAN: Miss Evans, we have no questions from the
  25     Panel. Mr Brooke?

   1   MR BROOKE: Yes, if you please, sir, just a few questions.
   2            RE-EXAMINED BY MR BROOKE:
   3   Q. Miss Evans, I am looking at page 10 of the transcript
   4     where you were asked about how far the emergence of
   5     concerns would have affected your negotiation of the
   6     first contract after de-designation and after the first
   7     year of float over.
   8        It might help to know: at what period would that
   9     contract for 1995/96 have been negotiated?
  10   A. It would have been negotiated mainly in the period
  11     between January and the end of March 1995. Where we
  12     wanted to change specifications or change quality
  13     requirements, the local agreement was we would try and
  14     discuss those between October and December, leaving
  15     January to March as the period for new issues or more
  16     difficult to resolve issues.
  17   Q. Very well. On page 24, at the end of your answer at
  18     line 14, you said:
  19        "Managers and clinicians had to go through a huge
  20     cultural change in getting used to", and the transcript
  21     records you as saying "huge organisations working
  22     together on the planning of health care". I heard you
  23     as saying "two organisations". We are talking about
  24     UBHT and the District Health Authority.
  25   A. Yes. UBHT was a huge organisation and the Health

   1     Authority is not a huge organisation, so I hope I did
   2     not cause confusion there.
   3   Q. At page 25, line 17, you were being asked about
   4     a "minute" by Miss Grey -- maybe I do not need to call
   5     it up -- document HA(A) 17/58. In fact, if you
   6     remember, that is a report for a meeting and it is
   7     a report by you?
   8   A. Yes.
   9   Q. At page 35 Miss Grey asked you about a smaller number of
  10     cases referred on. The Health Authority could not
  11     expect to claw back any of the sum that it had paid to
  12     UBHT, but the hospital instead was standing to gain in
  13     those circumstances. You are recorded as saying &q