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FULL TRANSCRIPT

   1                    Day 52, 20th September 1999
   2   (10.30 am)
   3   THE CHAIRMAN: Good morning, everyone. Good morning,
   4     Mr Langstaff.
   5   MR LANGSTAFF: Good morning, sir. Sir, today we cover two
   6     of the blocks of evidence which concerns this Inquiry:
   7     the first is a revisiting of Block 2, the national
   8     scene, when our witness is Sir Graham Hart, who was
   9     centrally involved at the top of the Department of
  10     Health for some of the years in question, as his
  11     statement describes.
  12        Later on today we will return to what we will come
  13     to know as Issue J, the retention of tissue issue, and
  14     we will have the benefit of hearing from Ms Helen
  15     Rickard.
  16        Sir Graham Hart, would you come forward, please?
  17     Sir Graham, we have a practice of standing to take the
  18     oath.
  19            SIR GRAHAM HART (SWORN):
  20            Examined by MR LANGSTAFF:
  21   Q. You are Sir Graham Hart?
  22   A. I am, indeed.
  23   Q. Can we have please on the screen WIT 40/1? Is that the
  24     start of your statement?
  25   A. Yes, it is.

   1   Q. In which you describe how, in 1985 as a Deputy Secretary
   2     Grade 2, you became the Director of Operations at the
   3     NHS Management Board, and worked as that until the end
   4     of 1989, and then from March 1992 until November 1997,
   5     you were Permanent Secretary at the Department of
   6     Health?
   7   A. Correct.
   8   Q. Can we turn to page 44? Is that your signature at the
   9     foot of the statement?
  10   A. It is.
  11   Q. Are the contents of that statement true?
  12   A. They are.
  13   Q. It is our practice to take the statement as read, so the
  14     questions which I ask will be questions around and
  15     following from the statement, but I will not ask you
  16     about the contents of it.
  17        You set out in paragraph 2, if we return to
  18     paragraph 2 of the statement, the ideas of duty,
  19     responsibility and accountability, using all three words
  20     in that paragraph.
  21        So far as the Department was concerned, someone in
  22     your position, how far did you see the responsibility of
  23     the minister of state extending for the day-to-day
  24     operations in hospitals?
  25   A. There is always, I think, a slight paradox about the

   1     arrangements that have been in place since 1948, because
   2     in the legal sense the Secretary of State as it now is
   3     has an overall responsibility for the service and he is
   4     accountable to Parliament for that. He will be
   5     questioned about anything and everything that goes on in
   6     the NHS.
   7        But in practice, of course, it is a vast service
   8     with millions, I suppose, of things happening every
   9     week, with hundreds of thousands of employees, and lots
  10     of hospitals and so on. It is simply impracticable for
  11     the Secretary of State to be in any detailed sense
  12     responsible for what goes on every day in every
  13     hospital.
  14        So Parliament provided that there should be set up
  15     and there should be accountable to him various statutory
  16     bodies who would carry out those responsibilities on his
  17     behalf.
  18        So the Secretary of State was not, and to my
  19     knowledge is not, as it were, routinely involved in what
  20     goes on in every hospital in the country. It does not
  21     mean that he does not take a very considerable interest
  22     in what has gone on, or may go on, in a particular place
  23     at a particular time for some special reason.
  24   Q. So obviously the fact of size means there has to be
  25     a division of function even if not of responsibility,

   1     and do I take it from what you are saying that the
   2     Secretary of State, although he has a nominal
   3     responsibility for the whole of the National Health
   4     Service, in fact concerns himself with what one might
   5     describe as "policy issues"?
   6   A. Generally speaking. As I have said I think later on in
   7     the statement, the Department's responsibilities --
   8     functions, at any rate -- tend to be very much of a kind
   9     of strategic and general kind related to policy, to the
  10     provision and distribution of resources, and at a high
  11     level, I suppose, the implementation of policy and
  12     performance, although, as I say in my statement, I think
  13     these are rather more problematical areas and ones
  14     where, over the years, I think probably the position has
  15     changed somewhat. I think these days there is a greater
  16     interest at the centre in policy implementation and
  17     performance of the NHS than there was originally. That
  18     is an area where I think attitudes have changed
  19     somewhat, practice has changed somewhat, over the
  20     years. But the fact remains that it is quite
  21     impractical, and I think wrong, for the Secretary of
  22     State or the Department on his behalf to try to
  23     superintend or supervise or be involved in routinely
  24     what is going on in each and every hospital, health
  25     centre and so on. It is just not practicable.

   1   Q. So what is required, presumably, is that there are
   2     structures in place by which, if necessary, the centre
   3     and the top, the Secretary of State, can be informed
   4     about what is happening at the -- one might call it the
   5     very bottom of the ward in a general hospital somewhere
   6     in the remoter parts of England?
   7   A. You need structures in place to -- you said to be
   8     "informed about". Up to a point it is not possible to
   9     be informed about everything that is going on,
  10     obviously, so you need to concentrate on the things that
  11     you think are of strategic importance, if I can put it
  12     that way, but of course what often happens, and I think
  13     inevitably happens, is that things happen in the NHS
  14     which require ministerial attention and action, which
  15     you have not been informed about in advance, you have
  16     not picked up from your as it were routine monitoring
  17     systems, whatever they are to be, which come to your
  18     attention because people bring them to your attention,
  19     whether it be the press or whether it be patients or
  20     people involved in the service. There are a whole lot
  21     of ways that the Department is constantly being informed
  22     about what is going on in the NHS, and its own internal
  23     management monitoring systems are probably one of the
  24     smaller contributors, as it were, to the Secretary of
  25     State's knowledge about what is actually happening.

   1     I mean, you just have to read the newspapers these days
   2     to see that.
   3   Q. So in terms of the structures, they should deliver the
   4     performance for the National Health Service for which
   5     the Secretary of State at the top is responsible. So
   6     far as policy is concerned, policy involves priorities,
   7     does it?
   8   A. Certainly, yes.
   9   Q. Who sets the priorities for health in the Department of
  10     Health?
  11   A. Gosh, that is a pretty general question. I mean, any
  12     important statement about policies or about priorities
  13     would be taken by ministers on advice from officials and
  14     possibly from people outside the Department, which set
  15     of officials would obviously depend on the subject. If
  16     you are asking about the National Health Service, ever
  17     since 1985 most of the advice that ministers would have
  18     had about the NHS would have come from the NHS
  19     Management Board, later the NHS Management Executive,
  20     although again, as I say in my statement, there was
  21     a period of some I suppose it was about 9 years when
  22     responsibility for some aspects of Health Service policy
  23     was not with the Management Board but with a separate
  24     policy directorate, if you like, elsewhere in the
  25     Department.

   1        But essentially, officials advising ministers on
   2     anything of any real importance or significance.
   3   Q. Can I stay with the issue of how one approached the
   4     development of policy and priority, given what happened
   5     after Griffiths. What you tell us in your statement is
   6     that following Griffiths, the NHS Management Board was
   7     set up. The way in which you describe it -- the top of
   8     page 3 [WIT 40/3] -- is that the NHS Board at the start
   9     did not have responsibility for policy on a wide range
  10     of issues relevant to the NHS, for instance, acute
  11     services. Those policy issues, you say, "remain the
  12     province of an administrative Deputy Secretary command
  13     (the Health and Social Services Policy Group)". You go
  14     on to describe how the Supra Regional Services Advisory
  15     Group you see as being part of the Deputy Secretary
  16     command to which you refer in paragraph 9. I have
  17     understood that correctly, have I?
  18   A. I do not want to be nit-picky. It was not technically
  19     part of anybody's command. It was an advisory group
  20     chaired by a regional chairman who actually stood
  21     outside the departmental structure. It was outside
  22     people serviced by officials from within.
  23   Q. Let me come back to that and how it fitted in, but so
  24     that we understand, why was it that some health policy
  25     was divorced from other health policy following

   1     Griffiths and until the later report on the situation
   2     from 1995?
   3   A. I was not involved in the original decision to structure
   4     the departments in 1985 in the way that it was done, but
   5     I think probably the rationale for doing it in the way
   6     that it was done was a two-fold belief: a belief that
   7     the Management Board which was then going to be a very
   8     new setup and structure would have so much on its plate
   9     in terms of getting the Griffiths report implemented and
  10     so on, that it was probably wise to keep work which
  11     could be separated off, separated off to as it were ease
  12     the load.
  13        I think probably the second reason that people had
  14     was a belief which I personally never shared, and
  15     certainly do not now share, but a belief that you could
  16     perhaps even beneficially, certainly it was possible to
  17     separate policy from management and its implementation,
  18     and that that separation might be even beneficial
  19     because it, as it were, enabled the policy issues and
  20     the management issues to be more clearly seen, if you
  21     like. If you, as it were, mix them up by putting them
  22     in the same body, one might pollute the other, and
  23     somehow you might retain some purity of the process, if
  24     I can put it that way. You have policy being clearly
  25     decided in one part of the organisation and management

   1     and its implementation being managed in another.
   2     I never shared that view, although of course I accepted
   3     the structure we had and worked with it. But we did
   4     change it, as I say.
   5   Q. When you say that the NHS did not have responsibility
   6     for policy on a wide range of issues, do I take it that
   7     it had responsibility for policy on some?
   8   A. Yes, certainly.
   9   Q. So it was not the clean division that the argument in
  10     favour of separating management from policy would imply?
  11   A. No. Its policy responsibilities related to issues which
  12     are, it has to be said, of the essence of management,
  13     for example, in relation to personnel practice in the
  14     NHS, in relation to finance, how the NHS should be
  15     financed, how much money it should have, how that should
  16     be distributed, those sorts of issues which are policy
  17     issues but also are about how the NHS is managed were
  18     always with the Executive. Really policy about services
  19     and acute services would be an example, or about mental
  20     health, for example. Those issues were kept separately
  21     in the Health and Social Services Policy Group.
  22   Q. So you had two separate parallel streams of
  23     organisation, did you?
  24   A. Yes.
  25   Q. And your own view, you never accepted that was

   1     a sensible way of organising matters, although you had
   2     to accept it?
   3   A. Yes. I accepted it, Mr Langstaff, and I worked with
   4     it. I just had my own personal reservations about
   5     whether it was the ideal way of doing things.
   6   Q. Why was it not?
   7   A. Why was it not the ideal way of doing things? As I say
   8     in my statement, in the 1990s we had the whole issue of
   9     departmental organisation looked at by a former
  10     colleague, Mrs Banks, and she took the view (which
  11     I agreed with) that it would be better to include the
  12     policy for the NHS and about the NHS in the Executive
  13     because that would make it more likely that the making
  14     of policy was properly informed by management and, as it
  15     were, the practical implications of it, firstly.
  16     Secondly, that the implementation of policy would be
  17     carried out in a way that was more understanding and
  18     accepting of the policy considerations that had led to
  19     the policy.
  20        I am sorry, I do not know whether that is clear or
  21     not. Do you want me to try again? Have I expressed
  22     myself clearly?
  23   Q. I think it is clear, but for the benefit of others, if
  24     you want to try again, please do so.
  25   A. I think it is important for the people who implement the

   1     policy to understand it; to have been involved in a very
   2     close way in its formulation, and last but not least, to
   3     have it in the right place in their order of priorities.
   4        That is more likely to happen if it is their
   5     policy than if it is the policy that somebody else has
   6     devised, albeit in consultations, and then, as it were,
   7     presented to them for implementation.
   8        It may be that this is not the way that things
   9     should be, but it is in the real world the way that
  10     people actually behave, so I always felt it was
  11     important for the Executive to be closely involved in
  12     that, indeed, responsibility for the whole range of NHS
  13     policies, which is the position that we achieved in
  14     1995, and which I think still obtains today.
  15   Q. You mentioned a moment ago the way in which the Supra
  16     Regional Services Advisory Group fitted in or did not
  17     fit in to the parallel systems that we were describing.
  18   A. Yes.
  19   Q. Can I again understand the relationship between the two
  20     parallel streams, the management stream and the policy
  21     stream, to the Supra Regional Services Advisory Group.
  22        It was an Advisory Group for the Minister?
  23   A. Certainly.
  24   Q. To whom did it report?
  25   A. Obviously at one level to Ministers. No, I think the

   1     answer unequivocally to your question is to Ministers.
   2     I do not think it reported to any official in the
   3     Department; it reported unequivocally to Ministers.
   4   Q. So to what degree would the policy stream be informed in
   5     advance, let us suppose, of the advice that was likely
   6     to go to a Minister from a body which inevitably was
   7     going to be concerned with policy so far as
   8     supra-regional services were concerned?
   9   A. The Department provided the Secretariat, as you know
  10     because you have taken evidence, from the officials
  11     involved on the medical and on the administrative side.
  12     Those were two post-holders within the policy structure
  13     that I was describing earlier, not part of the
  14     Executive: Dr Halliday, I think, throughout the period
  15     and various administrators.
  16        They would obviously be deeply and closely
  17     involved in everything that the group did, because they
  18     wrote the papers, or many of the papers -- not all of
  19     them probably, but they wrote the papers, organised the
  20     meetings, took the minutes; they would brief the
  21     Chairman, and so on.
  22        As to how far the Management Executive was
  23     involved in all that, I think their involvement would
  24     have been -- I speak without personal involvement in all
  25     this, but I think the Management Executive's involvement

   1     would have been at a very general level later on in the
   2     process; in other words, at the point at which decisions
   3     were being taken about how much money would be set aside
   4     for spending on supra-regional services and where that
   5     fitted into the overall scheme of things, and about the
   6     arrangements for actually distributing those sums of
   7     money. That all would be handled by the finance side of
   8     the Management Executive. That really comes at the end
   9     of the process.
  10        I think the argument so far as officials were
  11     involved in the discussions about how the supra-regional
  12     services arrangements actually worked at the front end,
  13     that would be very much for the policy side, until 1995,
  14     when, as I have said, the arrangements were changed.
  15   Q. What you have described is the officials from the policy
  16     side, both the medical and administrative, having an
  17     input into the Supra Regional Services Advisory Group
  18     discussions, inevitably because of their involvement
  19     from the policy side of the Department of Health.
  20        What you have not described as yet is any feedback
  21     from them to the policy side and any subsequent
  22     interaction by the policy side with the decisions the
  23     Supra Regional Services Advisory Group might make or the
  24     advice it might give to Ministers.
  25   A. I am not sure whether I understand the point, but let me

   1     try, and tell me if I am on the ball here.
   2        What would happen, I think -- I was never
   3     involved, but my guess would be this was how things were
   4     done.
   5        The Supra Regional Services Advisory Group would
   6     meet. They would consider papers. They would take
   7     decisions. Those decisions would, as it were, take the
   8     form of recommendations to Ministers.
   9        Officials in the Department on the policy side
  10     would then brief Ministers, inform Ministers, about
  11     those decisions -- I mean, maybe not after every
  12     meeting, obviously it would depend on what would take
  13     place at the meeting, but when there was something that
  14     needed to be decided or to be done of importance, then
  15     either Dr Halliday or one of his administrative
  16     colleagues, they would presumably agree between them who
  17     would handle it, would put a submission up the line
  18     which would go to Ministers.
  19        Officials from the Management Executive might well
  20     be involved at that stage, if, for example, there was an
  21     issue of money which would involve looking at priorities
  22     for NHS spending, for example. Then certainly the
  23     finance people in the Management Executive would be
  24     involved. Indeed, they might have been involved at an
  25     earlier stage. They would certainly be involved at the

   1     stage at which a submission was being drafted for
   2     Ministers. And they might even be involved in
   3     discussions with Ministers if there was a meeting or
   4     something of that kind.
   5   Q. So the likelihood is, and you are speaking I appreciate
   6     from a general experience rather than particular
   7     experience of the Supra Regional Services Advisory
   8     Group, but your general expectation would be that the
   9     process of reporting to a Minister would involve
  10     probably the Minister having discussions with the two
  11     streams in the Department of Health, both policy and
  12     management, so that --
  13   A. Depending on the content, yes.
  14   Q. So that the advice itself was not, as it were,
  15     self-contained and removed from any other advice which
  16     the Minister was going to get?
  17   A. No, and the arrangements -- despite this division of
  18     responsibility that I described earlier in the
  19     Department, as I think again I say in my statement
  20     somewhere, there was a kind of house rule that whenever
  21     you were handling a piece of business that affected or
  22     had repercussions for another part of the office, you
  23     consulted and you informed and made sure that people
  24     were preferably happy, certainly knowledgeable about
  25     what you were doing, and that the whole Department

   1     operated as a single organisation.
   2   Q. We know from evidence we have had thus far in this
   3     Inquiry that each year the Secretary of State made an
   4     announcement about the supra-regional services and their
   5     funding for the following financial year. Under his
   6     name, does one anticipate that that is something which
   7     he, or at any rate a Minister in the Department, would
   8     have seen?
   9   A. Certainly.
  10   Q. At one stage -- again, if necessary we can call up the
  11     documents -- the Minister considered, in his paper for
  12     the forthcoming year, the future of neonatal and infant
  13     cardiac services as a designated service. We have heard
  14     in this Inquiry how, in the late 1990s, the mid-1990s,
  15     it became de-designated, the issue being that the advice
  16     that was being given from the Medical Royal Colleges and
  17     by the doctors to the effect that a small number of
  18     centres doing the work, six or seven was appropriate.
  19     The fact was that 13 were actually doing significant
  20     numbers of operations. The profession did not, we have
  21     heard, recommend a reduction from the 11 that were
  22     recognised down to 6 or 7, although it was prepared to
  23     suggest that 2, at least, might be de-designated, and
  24     the ultimate result was that a system thought to be in
  25     the public interest in terms of benefiting patient care

   1     was abandoned because of the proliferation, contrary as
   2     I have indicated, the evidence goes, to what was seen to
   3     be in the patient's interests.
   4        That is plainly a policy decision that was
   5     reached, and reached in the Minister's name ultimately,
   6     upon the advice of the Supra Regional Services Advisory
   7     Group.
   8        Can you help me with the level of decision-making
   9     that would have been involved, probably, in putting such
  10     decision to a Minister for his approval?
  11   A. I do not know about this particular case. I wonder,
  12     before I answer, whether I could just ask you,
  13     Mr Langstaff, you said the decision was taken "in the
  14     Minister's name", I think were the words you used.
  15     I would have expected that decision on de-designation to
  16     be taken by a Minister. Was that in fact the case?
  17     I do not know myself.
  18   Q. One has to assume so, because he says it was.
  19   A. Yes. You are asking me from what level in the
  20     organisation I would have expected that recommendation
  21     to go to Ministers? Is that your question?
  22   Q. It would come from the Supra Regional Services Advisory
  23     Group.
  24   A. But it would come with a submission from officials
  25     saying "Here is a report from the Supra Regional

   1     Services Advisory Group", I would expect, "This is what
   2     we think about it and here are the issues that you need
   3     to consider, you need to be aware", you know, on the
   4     pro side, on the con side. "Will you please tell us
   5     your decision". It might end up with a very positive
   6     steer to Ministers to either agree or disagree, or it
   7     might just leave it open and say, you know, "We give you
   8     no steer, but here are the pros and cons, what do you
   9     think?"
  10        I do not know at what level that submission was
  11     made to Ministers. It could have been made at any level
  12     from grade 7 on the administrative side up to a much
  13     higher level. I think it just depends on all sorts of
  14     factors like whether Ministers were already apprised of
  15     all this and aware of it and it was just really the last
  16     coping-stone, so to speak, in a process that had been
  17     going on for some while, or whether it was some new and
  18     novel issue they had not addressed before; it would
  19     depend on how controversial people thought it was, how
  20     significant, how important it was. So it might have
  21     gone from a relatively junior level or from a relatively
  22     high level. I think it just depends on the context.
  23   Q. Let me approach the same question in a slightly
  24     different way. When heart transplants first became news
  25     in the 1960s, I think, following the work of Barnard and

   1     others, were they widely performed, or was it suggested
   2     by the medical profession that they should be widely
   3     performed in the United Kingdom?
   4   A. I do not think they were -- I mean, at the time, if you
   5     are talking about right at the beginning, of course it
   6     was a very experimental process, and a rather
   7     controversial one, for all sorts of reasons, not just
   8     medical reasons. It is hard to think back to those
   9     days, but I think there were probably even ethical
  10     considerations, too, that were being floated about organ
  11     transplantation, or heart transplantation. So I do not
  12     think it was something that was going to be taken up in
  13     a widespread kind of way, but it certainly was something
  14     which, in my recollection -- I was not involved at all,
  15     but my recollection is that there were people in this
  16     country who quite naturally wanted to take it up and to
  17     do it. I think there were a number of procedures of
  18     that kind carried out at quite an early stage. Then, if
  19     my memory serves, we stopped. I mean, we, the British,
  20     we stopped. We did not do any transplants for quite
  21     a period, I think.
  22   Q. Why was that, as your memory serves?
  23   A. My memory is not based on personal involvement, it is
  24     based on what I have read in print probably around this
  25     general knowledge, but I think what happened was -- you

   1     would need to check this if it matters with the people
   2     involved, but my belief is that what happened was that
   3     the Chief Medical Officer of the day took the view --
   4     possibly Ministers took the view, I do not know -- that
   5     this was something which he wanted to be rather cautious
   6     and careful about, so discussions were had. And the
   7     surgeons concerned agreed to desist for a while until
   8     greater expertise and greater experience could be built
   9     up on doing this procedure.
  10        But that is to my knowledge. There may well be
  11     others. You are really talking to the wrong person, you
  12     really need to talk to doctors about this. My
  13     perception would be that that was a very, very unusual,
  14     if not unique, episode.
  15   Q. What you are describing is a process by which central
  16     influence, at any rate, or control, managed to prevent
  17     or dissuade an operation of a certain type being
  18     conducted --
  19   A. Influenced.
  20   Q. And the net consequence of that, as one understands, has
  21     been that transplants are, today, carried out in
  22     a number of centres in the UK -- a few centres with some
  23     considerable success, comparatively speaking.
  24        So far as operations such as those on the hearts
  25     of infants suffering from congenital heart disease are

   1     concerned, was there, as you would see the role of the
   2     Department of Health, anything that the Department of
   3     Health could have done, perhaps by analogy with the
   4     pressure brought to desist from transplant operations,
   5     to restrict those operations to a few limited centres in
   6     the interests of patient care?
   7   A. Of course the whole supra-regional services setup
   8     was indeed designed to encourage -- and I used the
   9     word "influence" earlier, and I am going to use the
  10     word "encourage" -- the performance of these very
  11     specialised supra-regional services by a relatively
  12     small number of centres, and, if you like, therefore by
  13     implication, at least, to discourage their performance
  14     by anybody who just felt like having a go.
  15        So the very existence of the supra-regional
  16     services arrangements was certainly designed partly to
  17     meet that need.
  18        If you are asking me what influence was brought to
  19     bear or could be brought to bear on units which
  20     performed these procedures outside the supra-regional
  21     services arrangements, again, I think the answer is that
  22     that would have to be a question of persuasion and with
  23     the use of influence. I think it is very questionable
  24     what, as it were, legal powers the Secretary of State
  25     would actually have had to stop a unit from carrying out

   1     such procedures. I think -- I am not a lawyer, you
   2     would have to ask yourselves -- but you would certainly
   3     have to take legal advice on this matter as to how far
   4     the Secretary of State's actual powers would extend, and
   5     they might not extend that far. Certainly I think you
   6     would have to have some pretty good reasons for trying
   7     to stop somebody, not just a kind of general policy, you
   8     would have to be able to show there is some good reason
   9     why these people should be stopped from doing it.
  10        That is just on legal powers. There is another
  11     point which -- shall I go on?
  12   Q. Yes, please.
  13   A. There is another point that I think in the real world
  14     a Minister would always think twice or three times
  15     about, as it were, entering into a controversy with
  16     a particular unit or series of units by saying, "I want
  17     you to stop doing this", unless, as I say, there was
  18     some really good evidence. If it was going very badly
  19     wrong and it was quite clear that this should not be
  20     done, that is one situation. But if his only ground for
  21     doing it was, "We have this general policy which is in
  22     favour of these procedures being done in a few centres
  23     and that is why we have supra-regional services and you
  24     are not one of the chosen few, so to speak, so I want
  25     you to stop for that reason", I think that would be

   1     a very difficult argument to carry off in a situation of
   2     public controversy.
   3        When the Secretary of State or Minister was
   4     confronted, so to speak, in the argument, in the debate,
   5     with probably a very highly qualified consultant, who
   6     arguably in his view had the skills, could find the
   7     resources, had the patients in front of him, could say
   8     to the public, "Look, I have got the means, I have got
   9     the patients, I should be treating them, it is my
  10     ethical duty to be treating them. Here they are, if you
  11     forbid me from doing so or try to stop me from doing so,
  12     my only choice then is to, as it were, pass them on to
  13     a colleague 50 or 100 miles away who may already have
  14     quite a long waiting list".
  15        And further to that point, how do we make
  16     progress? Many of these procedures, it was clearly
  17     envisaged would, as it were, take off. More and more
  18     patients would be found to be suitable for them, the
  19     techniques would develop and so on and so forth, so
  20     something which at one time was very, very exceptional
  21     and rare and done in one or two centres, as with heart
  22     transplantation, would later become almost -- perhaps
  23     not routine, but very widely done in a lot of centres.
  24     How can you expect this procedure to be extended if you
  25     just put a kind of bureaucratic blanket on anybody

   1     acquiring off their own bat the skills and the resources
   2     to do it?
   3        So I am putting an argument that I think would
   4     have been put if the Secretary of State had tried to, as
   5     it were, put on his hobnailed boots and go down to
   6     a particular place and say, "Stop doing that". You
   7     could have done it, but it might not have been very wise
   8     and I think you would have had to have had some very
   9     good specific reasons, not just general reasons.
  10        None of that is in a sense quite on the point of
  11     Bristol, which of course was designated as a centre at
  12     the beginning, and remained one I think throughout the
  13     time that this subspecialty was a designated one.
  14   MR LANGSTAFF: So what you are saying to me is that the
  15     relationship between the Secretary of State, the
  16     Department of Health, the hospitals and the consultants,
  17     was such that even in a situation in which medical
  18     advice was, let us suppose, unanimously to the effect
  19     that, leave aside for the moment heart disease,
  20     a particular procedure would be more successful in, let
  21     us suppose, three or four centres only, if restricted to
  22     those, that there was in practical terms nothing that
  23     the Secretary of State or the Department would, or
  24     could, realistically do to prevent it in fact being
  25     conducted in 12, 13, 20, however many centres actually

   1     decided they wanted to do the job?
   2   A. No, I think that is an overstatement. I think there are
   3     constraints. They are partly as it were peer opinion
   4     constraints in the sense that if the hypothesis is, as
   5     you say, that the professional advice was unanimous,
   6     I do think it is uncharitable, and I think probably
   7     wrong, to say that every consultant in the country will
   8     ignore that view. I think many people would accept it
   9     and go with it.
  10        Secondly, I think there were things on the
  11     narrower point of what could Ministers and the
  12     Department do, I think as I said at the beginning, the
  13     supra-regional services arrangements were themselves
  14     a reasonable effective mechanism for encouraging and
  15     influencing things in the sense of limitation. I can
  16     expand on that, if you like. Thirdly, as I have said,
  17     I think that the Secretary of State could have
  18     intervened and taken action on particular cases, but as
  19     I said to you, only I think if there was some pretty
  20     good reason for doing so. My understanding is that --
  21     it is certainly perfectly thinkable -- that some of the
  22     units that were doing these procedures outside the
  23     supra-regional services arrangements had a good record.
  24        So why should he, in a sense, intervene? I think
  25     he created the right kind of environment in which the

   1     tendency would be towards limitation and specialisation,
   2     but he was not, as it were, putting down an absolutely
   3     rigid framework within which there was no room for
   4     movement at all.
   5   Q. Sir Roy Griffiths, when he began to work on his report
   6     in 1983 and produced it in 1984, likened the National
   7     Health Service to industry and used, as one understands
   8     it, an industry model against which to measure the
   9     management systems in the National Health Service.
  10        If one were approaching the issue that I have just
  11     been canvassing with you as an issue coming before the
  12     Board of albeit a very large corporation, and the
  13     question is put to the Board, "We are producing this
  14     particular product in 20 factories; some of the
  15     factories, actually, some of the lines do it very well,
  16     but it would be more efficiently and better produced in
  17     four", one anticipates what the normal commercial board
  18     would pretty quickly achieve, because after all, it
  19     controls the purse strings and directs the operation.
  20        What are you saying are the constraints on the
  21     National Health Service that prevented it acting in that
  22     way, even post-Griffiths?
  23   A. It is a common misconception. I do not think that Roy
  24     Griffiths thought you could run the health service like
  25     Sainsbury's. He never thought that. He had a very good

   1     understanding of the Health Service, and in particular,
   2     of the very considerable and proper influence which the
   3     medical profession and the consultants individually have
   4     within it. A hospital is not like a supermarket, and
   5     the Health Service is not a supermarket chain. You may
   6     be right, that the decision about whether to open or
   7     close a factory, or indeed a supermarket, is taken
   8     routinely at the Board of the supermarket chain. The
   9     Health Service is not like that; it never has been.
  10     Perhaps it is slightly more like it these days than it
  11     was 10 or 15 years ago. But I come back to the point
  12     that I was making to you earlier, Mr Langstaff, which is
  13     that there are a whole series, many hundreds of
  14     statutory bodies set up by Parliament who are
  15     responsible for running the services locally, and who
  16     have a responsibility to decide what goes on in those
  17     hospitals. That is bound, and very properly, to dilute
  18     the power which lies at the centre.
  19   Q. So you are giving me as one reason the balance of local
  20     and central power?
  21   A. Sure.
  22   Q. Despite what you say in your statement and have
  23     confirmed to me earlier, that at a central level the
  24     distribution of resources is controlled, the degree to
  25     which those resources are allocated or hypothecated to

   1     one particular form of treatment or one particular type
   2     of unit is left, is it, to the region or the district or
   3     whatever the body happened to be at the particular time?
   4   A. Correct. As a generalisation, correct. Obviously the
   5     supra-regional services themselves were an exception to
   6     that in the sense that you were taking a sum of money,
   7     an earmarked sum of money and separating it off from the
   8     generality of the funds for the Health Service, and
   9     Ministers were saying, "We will allocate so many 10s or
  10     100s or whatever it was, of millions, to the supra-regional
  11     services and they will be allocated in the following
  12     amounts". That was a justified arrangement because of
  13     the nature of the supra-regional services, but the great
  14     generality of Health Service funds were not, to use the
  15     term of art that we then used, top-sliced, removed from
  16     the general pool and allocated to specific purposes.
  17     That was unusual, and the whole weight of the system and
  18     Ministers were always very keen to minimise that as far
  19     as possible, because they wanted to maximise the degree
  20     of discretion which the local health authorities had for
  21     determining their own priorities and for their sense of
  22     responsibility for what they were doing. Obviously, if
  23     you dictate from the centre exactly how the money is
  24     going to be used, that removes any real responsibility
  25     from the local body, which is not desirable.

   1   Q. I understand the point you are making in the context of
   2     the fairly simple hypothetical example that I put to you
   3     of the operation best conducted in three or four centres
   4     but in fact conducted in 20 or more. The proposition
   5     that it was best conducted in three or four centres
   6     would of course be at a national level and could only be
   7     seen at a national level. Does it follow from the way
   8     in which you are describing the relationship between the
   9     centre and the regions or districts that taking such
  10     a national perspective and requiring the policy of the
  11     regions or districts to be within the framework of that
  12     national policy, was not something which practically
  13     speaking was open in the 1980s and 1990s to the
  14     Department of Health?
  15   A. I think it is a matter of degree, really, Mr Langstaff.
  16     I do not know that -- I think you are perhaps kind of
  17     slightly stretching the facts, are you not, possibly in
  18     relation to --
  19   Q. I am putting a hypothesis to inspire an answer.
  20   A. If you are not talking about paediatric cardiac surgery
  21     (where I understand there is a discrepancy between the
  22     number of designated centres and the number doing it;
  23     it is much narrower than the kind of span you are
  24     talking about) and you are talking about a hypothetical
  25     case in which the centre had decided on no doubt very

   1     good professional advice that three or four centres was
   2     the desirable number and it had proliferated to the
   3     point of 20 or more, then I think the first comment that
   4     one would make on that is that clearly in that
   5     hypothetical case, something has very badly gone wrong,
   6     something is wrong somewhere. Either the policy is
   7     wrong or a whole lot -- not just a few, but a whole lot
   8     of people have taken leave of their -- not taken leave
   9     of their senses, perhaps, but certainly are overreaching
  10     themselves, and I think you would want to sort that out
  11     in one way or another, you would want to have another
  12     look at the policy and you would want to have a look
  13     very closely at the results that the people in the 16 or
  14     17 units who were not designated were getting.
  15        As I said all along, if those results were pretty
  16     good then I think you would have to rethink your
  17     policy. If they were pretty bad, then you would want to
  18     do something by way of persuasion, and persuasion can,
  19     you know, take various forms and be quite powerful. If
  20     the results were really bad, if it was an absolute
  21     scandal that was going on here, then I think the
  22     Secretary of State would probably be able to use such
  23     legal powers as he had, but one would hope it would
  24     never come to that in the sense it would never be that
  25     bad. But persuasion can be pretty limited. I am not

   1     aware of any case under the supra-regional services
   2     advisory arrangements that really got quite out of
   3     kilter in the way that your example does.
   4        May I say one further word about, as I always
   5     understood it, not being personally involved in the
   6     supra-regional services arrangements, it was that those
   7     arrangements were, to use an analogy, a carrot, if you
   8     like, but it seems to me carrots can also be used as
   9     sticks, if you know what I mean, they can turn into
  10     sticks. What I mean by that is that if one looks at the
  11     hospital where the surgeons or physicians, surgeons,
  12     shall we say, wanted to branch out in a big way into
  13     a new field, which was a supra-regional services field,
  14     assuming that hospital is well-run, they would have to
  15     persuade the management of the hospital to allocate
  16     resources for that to be done. There would be bound to
  17     be some pretty intense discussion about why that should
  18     be, in that particular place, given that there was
  19     central funding allocated for this service and this
  20     particular hospital was not in receipt of that funding.
  21     That would be a pretty big disincentive, I think, to the
  22     management of any hospital to indulge in that. They
  23     might be persuaded, of course, these things can happen,
  24     but it is not a walk-over, so to speak, on behalf of the
  25     entrepreneurial consultant; there would have to be some

   1     pretty difficult discussions about that before that
   2     happened.
   3        I think that probably was quite a powerful
   4     disincentive to people to start up these things in every
   5     conceivable place.
   6        On the other hand, on the other side of that
   7     equation, you have to say that people who were inclined
   8     to do that, and were doing this type of thing, were
   9     motivated I am sure by absolutely the best of motives,
  10     the desire to help patients and professional ambition,
  11     which is a good thing,to develop the work of their unit.
  12        So these are quite complex, difficult issues which
  13     did not have an absolutely clear-cut outcome in terms of
  14     "you are designated and you do it" or "you are not
  15     designated and you do not do it"; there was some
  16     fuzziness around the edges, some spillage around the
  17     edges, but I still think it is an important context of
  18     influence and the beginnings of a kind of discipline
  19     that helped to ensure that the services did not
  20     proliferate in the way that they certainly would have
  21     done if there had just been a kind of complete
  22     free-for-all, no policy, just "Do what you like, chaps".
  23   Q. The "Do what you like, chaps", is the response of the
  24     clinician who has clinical freedom to provide whatever
  25     treatment he thinks is in the best interests of the

   1     patient. You are describing, are you, to some extent
   2     the balance that was struck or it might be said by some
   3     has to be struck, between the needs of the funding
   4     agency to secure the result which is intended by the
   5     funding on the one hand with the freedom, if there is
   6     such, on a clinician to treat the patient as he best
   7     thinks the patient deserves to be treated?
   8        Do you see policy, the balance between those two
   9     considerations, as having altered during the period of
  10     your involvement in the Health Service, or not?
  11   A. Yes. I think it has, really, yes. I think if you go
  12     back to my early days, so to speak, of involvement in
  13     all this, which would be in the 1960s, and even roll it
  14     forward to the early 1980s, really, there was a feeling
  15     around -- this can be oversimplified -- that clinical
  16     freedom meant that the centre -- Ministers, in effect --
  17     should keep out of anything to do with the practice of
  18     medicine, if you like. I am putting that in a very
  19     stark way, but I think there was that kind of general
  20     belief.
  21        I think that over the years both the profession
  22     have come to accept -- perhaps their representatives
  23     would not say it quite like this, but they have come to
  24     accept more and more that Ministers have a legitimate
  25     interest here and have certain responsibilities to try

   1     and see that the quality of service that is given to
   2     patients is of the right kind, the right level, and that
   3     it is legitimate for Ministers to be interested in that
   4     and to try at least to set up certain kinds of procedure
   5     and process to try and ensure that that happens.
   6        On the other hand, I think that Ministers and
   7     officials, if you like, the Department, have over the
   8     years become somewhat more bold, ambitious in its
   9     approach to these things. This is how the world is, it
  10     changes, fortunately for all of us, and over the years
  11     I think things that would once have been thought pretty
  12     well unthinkable, certainly very, as Sir Humphrey would
  13     have described it, "courageous" things to do, are no
  14     longer regarded in that light but are regarded as
  15     perfectly acceptable things to do. So I think there has
  16     to be a change in perception. It is not total, but it
  17     is significant.
  18   Q. In the Griffiths report -- we will just have a look at
  19     some of the general comments which he made. It is
  20     HOME 3/12. This comes from Griffiths, it is page 10 of
  21     what is acknowledged to be a short but effective
  22     report. In paragraph 2, under his general observations,
  23     he describes the NHS not having a profit motive but
  24     being enormously concerned with the control of
  25     expenditure:

   1        "Surprisingly, however, it still lacks a real
   2     continuous evaluation of its performance against
   3     criteria such as those set out above ..."
   4   A. I am missing the right-hand edge of mine.
   5   Q. It must be the photocopying, I am sorry.
   6   A. I can take it from you, anyway, "such as those set out
   7     above..."
   8   Q. "Rarely are precise management objectives set. There is
   9     little measurement of health output. Clinical
  10     evaluation of particular practices is by no means common
  11     and economic evaluation of those practices extremely
  12     rare."
  13        Leaving aside the economic and leaving aside the
  14     question of output, the number of operations done,
  15     clinical evaluation of particular practices is by no
  16     means common.
  17        In this paragraph as a whole, what Griffiths
  18     appears to be observing, and the implication is,
  19     complaining about, is that the NHS had no proper
  20     measurement of the quality of the care it was providing
  21     in general terms.
  22        First of all, from your own perspective, was he
  23     probably right about that, at the time?
  24   A. Yes. I mean, I would say, I think, what he was saying
  25     was that there was no system, if you like. Some of

   1     these things happened, but they did not happen in an
   2     organised and systematic way. I think that is true. He
   3     was spot-on, there.
   4   Q. What you say about that -- I will take you back to your
   5     statement and to page 2, paragraph 6. You are talking
   6     here about the monitoring of the quality of clinical
   7     services.
   8   A. Yes.
   9   Q. You note that the position in the 1980s was very
  10     different from the position today.
  11   A. Yes.
  12   Q. You say this:
  13        "There is a deeply rooted reserve on the part of
  14     the department - shared by the professions - about
  15     departmental involvement in clinical performance."
  16   A. Yes.
  17   Q. To what extent is that a reflection of our discussion
  18     a moment or two ago about clinical freedom and the
  19     Departmental right or not to get involved?
  20   A. Yes, I think it is exactly a reflection of that view.
  21     I think it is founded on two things which I would
  22     slightly separate one from another. I mean, one is the
  23     feeling that Ministers who are politicians should not be
  24     involved in anything to do with the clinical treatment
  25     of patients. I think that is the kind of origin of

   1     this, if you like, a sort of nervousness that has been
   2     around when you introduce, as one did in 1948, a system
   3     which is publicly funded by Ministers; Ministers are
   4     accountable to Parliament, as I have said, they have of
   5     course to exercise some kind of responsibility, some
   6     kind of control therefore over the use of the money.
   7     That could easily lead them into how individual patients
   8     are treated and whether they are well-treated and so on
   9     and so forth. I think the profession, and Ministers on
  10     their part equally, have always been extremely nervous
  11     about that. That is, it seems to me, a rational worry
  12     and one which people have perfectly properly as it were
  13     reacted to.
  14        The second, which is a slightly different point
  15     but it flows from the first, is that of course if
  16     Ministers might be tempted to tread down that path of
  17     involvement and intervention, then they could be pretty
  18     sure that there would be a tremendous row about it with
  19     the profession, and that is something which you
  20     certainly do not want to do without forethought; any
  21     Minister or Secretary of State may well have lots of
  22     points of disagreement with the profession over many,
  23     many issues, potential disagreements at any rate, and if
  24     you are going to fight battles, you want to choose your
  25     ground very carefully and fight battles on ground you

   1     think are important and you are going to win on and not
   2     fight battles on things that are either unimportant or
   3     that you cannot win.
   4        So I think that this whole area is one that has
   5     been, as I have said, susceptible to change; there has
   6     been change, but I think most of that change has come in
   7     the last probably 15 years since about the time of
   8     Griffiths. I think Griffiths was an important milestone
   9     in this, but it was not the only factor. But my
  10     perception would be that for the first 35 years of the
  11     NHS very little happened; since the early 1980s things
  12     have begun to happen, I think at a fairly quick pace,
  13     but a measured pace and a pace which has attempted to
  14     make sure that everybody was reasonably comfortable with
  15     it.
  16        I think attitudes have changed and the world has
  17     changed with those attitudes.
  18   Q. So the deep roots that you describe there are roots that
  19     go back to 1948, are they?
  20   A. Indeed, and before, of course, but certainly from 1948.
  21   Q. And the reserve that you describe as being shared by the
  22     professions was in part and from what I have understand
  23     you to have said, from departments because of the view
  24     that departments saw the professions would take, if the
  25     Department got itself too heavily involved?

   1   A. Yes. I mean, it was -- yes.
   2   Q. So it was really because of the professions, rather than
   3     shared by the professions, that the Department had the
   4     reserve that it did?
   5   A. I am not quite sure I am following you, Mr Langstaff.
   6     I am being rather slow.
   7   Q. I am looking at the words you used and just exploring
   8     them.
   9   A. The profession had very deep reservations about the
  10     Department getting involved. Reservations which, to
  11     some extent, as I said earlier, on rational grounds, the
  12     Department shared, but I think the fact that -- the very
  13     fact that the profession -- this was at the core of much
  14     of the profession's concerns about the NHS, added
  15     another as it were political with a small p dimension to
  16     the subject, which added to the Department's caution on
  17     it; yes.
  18   THE CHAIRMAN: I rather think that what Mr Langstaff is
  19     saying is that the reserve in the Department is wholly
  20     prompted by the reservations of the profession;
  21     therefore to say it is shared by the profession suggests
  22     a partnership whereas in fact your description is very
  23     much one-sided?
  24   A. I see, yes, okay. Thank you, Chairman. I understand
  25     the point. Perhaps my statement is not totally

   1     felicitous in this respect. I think that it would be
   2     true to say that perhaps at the bottom, the fundamental
   3     concern is the profession's, and it is shared by the
   4     Department for both the reasons that I have given, for
   5     the, if you like, small p, political reason, but also
   6     for a rational reason.
   7   MR LANGSTAFF: And the implication would then be that
   8     the Department would perhaps have wanted to do more but
   9     felt constrained by what it saw as politically, with
  10     a small p, acceptable given the context?
  11   A. What period are you asking me about, Mr Langstaff?
  12   Q. From the 1980s onwards.
  13   A. Yes. Before, if you like, this came on the agenda in
  14     a serious way, as it did in the 1980s, I do not think
  15     the Department did have a sort of extensive agenda, so
  16     to speak, although it must be said that my perception is
  17     that in various ways, even before the 1980s, the
  18     Department did do its bit to try and encourage issues of
  19     quality to be addressed. I mean, I think I mentioned
  20     again in my statement, for example, that for many, many
  21     years, I do not know when it started, the Department had
  22     been responsible for a thing called the Confidential
  23     Enquiry into Maternal Death, and I am not an expert on
  24     this -- you will get lots of expert evidence on this --
  25     there were other similar mechanisms, so it is not as if

   1     one washed one's hands on this subject, but these were
   2     specific initiatives responding to a specific need and
   3     I think agreed with the kind of community that would be
   4     particularly affected by them, and I think operating
   5     quite successfully. But it was not part of, I think it
   6     would be fair to say, either our agenda or even our
   7     ambition, even, if you want to go back to the 1970s or
   8     1960s, or earlier, to put the quality of NHS clinical
   9     practice at the heart of the Department's management
  10     system. Our management systems were extremely
  11     rudimentary, but to put that at the heart would have
  12     been not within our ambition, I think, in those days.
  13     I think that world changed significantly in the 1980s
  14     because of what Griffiths said, because of what other
  15     people were saying. It was not just Griffiths, it was
  16     because of all sorts of things, and because I think the
  17     profession themselves came much more comfortable with
  18     the idea that they needed to do more and I think that
  19     Ministers and the Department also had a legitimate
  20     interest in this and it was a proper subject for debate
  21     and discussion.
  22   Q. Can you help me to unpick what you say in the next
  23     sentence. You say:
  24        "Clinical performance was in general seen as the
  25     preserve of clinicians", and then this phrase,

   1     "individually and to some extent collectively"?
   2   A. Yes.
   3   Q. What you are saying, or recognising as the view of the
   4     profession in the early 1980s, is that the performance,
   5     the results of an individual, was a matter for him or
   6     her alone, essentially, although collectively the
   7     doctors had some concern with it.
   8   A. Yes. I would not say -- I am really the wrong person to
   9     get into this.
  10   Q. It is your words I am asking you about.
  11   A. Yes, I know. I am really just giving my perception.
  12     I do not think that the generality of consultants, even
  13     in the 1980s, would have said, to use your words, "It is
  14     a matter for me and me alone". I think some might have
  15     said that.
  16        What I was getting at in the use of the word
  17     "collectively" was that there were some mechanisms, as
  18     I understand it, that were above the individual level,
  19     whether you are talking about colleges, whether you are
  20     talking about some of the kind of things I mentioned,
  21     like the confidential enquiries, whether you are talking
  22     about the management processes for hospitals, which even
  23     pre Griffiths had medical committees and a Chairman of
  24     the Medical Committee and a kind of peer interest in
  25     what colleagues were doing. Of course there was the

   1     GMC. Ever since 1858 there has been the GMC.
   2        So I think you would have to have been a fairly
   3     extremist person, even in the 1980s, to say "It is
   4     nothing to do with anybody, it is between me and my
   5     patient and that is the end of it and if you do not like
   6     what I am doing, I will see you in court", kind of
   7     thing. There may be some people who took that view, but
   8     that would be the very extreme end of the spectrum.
   9     I think that even then there was certainly a recognition
  10     that one was part of a wider community, part of
  11     a profession with its own standards of conduct and
  12     behaviour and so on and so forth.
  13   Q. To finish this particular part of my questioning, how do
  14     you see the situation as having changed since the 1980s
  15     and where do you see it going? The last few words in
  16     that paragraph, if we just scroll down, "the process is
  17     by no means concluded", is pregnant with interest.
  18   A. I am glad I have been able to --
  19   Q. Since you are no longer in the Department of Health,
  20     having retired, you are free to comment on what you see
  21     is happening, I think.
  22   A. I think this is very interesting, and I understand the
  23     Inquiry will be looking at all this later, but I do
  24     think this is extremely interesting. I do think there
  25     has been a great change since the mid-1980s in

   1     attitudes, as I say, and you can argue about whether the
   2     pace of change has been fast enough, whether it has been
   3     done well or badly, but I think you can just tick off
   4     a number of things that have happened since the
   5     mid-1980s, some of them things which have actually been
   6     done by officialdom, by the Department, some which have
   7     been done by the profession, some which have come about
   8     as a result of just a change in climate of opinion, the
   9     way in the real world these things happen. Clinical
  10     audit, which, as I say in my note, was certainly
  11     well-established in the 1980s, but it was partial and it
  12     probably has not yet reached the kind of penetration
  13     that it ought to have, or the kind of quality it has to
  14     have, but it has certainly revolutionised in coverage
  15     since the 1980s and a lot of money has been spent on
  16     encouraging it, I think initially, at any rate, very
  17     much by as it were enabling the profession to develop
  18     it. Again, I am not an expert on that, you can get
  19     evidence on that, but certainly there is far more
  20     clinical audit going on, and I think an acceptance now
  21     by probably every consultant in the country that it is
  22     something that he or she ought to be involved in and
  23     participating in and doing.
  24        The whole Griffiths process introduced -- or
  25     encouraged, at any rate -- more formal arrangements at

   1     hospital level for the management of clinical work.
   2     I use the word "management" in inverted commas, but the
   3     management of clinical work, which puts individual
   4     consultants in a more organised framework than was the
   5     case in most hospitals at any rate before that. That is
   6     a significant change. I think the GMC -- it is not
   7     really for me to comment on the GMC, I am sure you have
   8     heard lots from them, but it seems to me as an observer
   9     that the GMC takes a much greater interest in this whole
  10     question than it once used to, and looking to the future
  11     for the moment, as I understand it, they definitely have
  12     set their foot on the path towards some kind of periodic
  13     review -- I may be using the wrong words -- of clinical
  14     competence which does seem to me, if I may say so in all
  15     humility, to be right, and that is going to make a big
  16     impact. They should be encouraged in that, that is
  17     going to make a big impact in the future.
  18        I think the world has changed. Patients are much
  19     more alert to what is going on, they are much less
  20     accepting of what happens and what doctors seem to be
  21     saying to them. They are much more willing to complain,
  22     much more willing to sue. I am not saying that is good
  23     or bad, in some ways it is not a good thing but in other
  24     ways it is a good thing, and it certainly raises
  25     awareness in the NHS among clinicians and managers and

   1     so on of the need to attend to the level of clinical
   2     performance. You cannot any more say, "Well, it is no
   3     concern of ours"; you have to attend to it.
   4        I think another thing that has changed greatly is
   5     this whole business of what is known in the trade as
   6     "whistle-blowing". There was a time when -- and maybe
   7     it still is true to some extent, but there was a time
   8     when colleagues generally speaking were very reluctant
   9     to complain about the performance of a colleague. Some
  10     were. The general climate was rather unfavourable to
  11     that.
  12        I think that is changing, it has changed, very
  13     markedly. I think it has now been put beyond doubt by
  14     the authority so to speak that it is people's duty to
  15     speak up if they think things are not going well and
  16     there is something wrong. So that is a big change.
  17        Then you look forward to as it were the new
  18     agenda, which again I am not involved in, I was not
  19     really involved in its formulation, even, but the new
  20     agenda as I understand it from Ministers, the setting up
  21     of the Commission on Health Improvement which as
  22     I understand it, one of its main purposes is going to be
  23     to supervise and take a big interest in the quality of
  24     clinical governance, which is really what we are talking
  25     about here. We are talking about the processes and

   1     procedures by which clinical performance is monitored
   2     and hopefully improved.
   3        We have a new powerful central body that is going
   4     to be taking a big interest in all that and making sure
   5     as far as it can that it is judged by quality of
   6     performance. That again I think is a good thing. It
   7     has to be done well, but if it is done well, it will be
   8     a very good thing.
   9        So really, I think, even the world now is pretty
  10     different from what it was 10 or 15 years ago, and
  11     I think I can see no reason why, provided nobody plays
  12     their cards badly, we cannot move into a new era when
  13     these things are even better done, significantly better
  14     done, even than they are now. But I think it is well on
  15     the way.
  16   MR LANGSTAFF: Sir, would that be a convenient moment for
  17     our mid-morning or now perhaps early afternoon break?
  18   THE CHAIRMAN: Yes. Shall we break for 15 minutes and
  19     reconvene at 12.15?
  20   (12.00 noon)
  21            (Adjourned until 12.15 pm)
  22   (12.25 pm)
  23   MR LANGSTAFF: One matter of housekeeping before I ask more
  24     questions.
  25        If we can scroll back on anyone who has LiveNote's

   1     screen -- you will not have it, Sir Graham, I think --
   2     to page 31, line 2, Sir Graham is recorded as saying
   3     "but persuasion can be pretty limited", which is in
   4     fact the word he used. It is not, I think, what you
   5     intended to say? Perhaps you can tell us what you had
   6     in mind. Is persuasion "limited" or some other word?
   7   A. It can be effective is what I meant. I meant to say the
   8     opposite of what I apparently said.
   9   Q. So continuing then with the issue we were on, which was
  10     essentially audit and developments in audit since the
  11     early 1980s, the impression one might get from
  12     paragraph 6 of what you say is that the Department was
  13     in some way distanced from the development of audit and
  14     it was really something which the professions took upon
  15     themselves and the Department, obviously, were happy to
  16     encourage, but did not necessarily inspire.
  17        Is that the flavour that you meant to convey, or
  18     not?
  19   A. Yes. It depends on what you mean by "inspire". I think
  20     we encouraged it, we were supportive of it, but I think
  21     it was only really probably following Working for
  22     Patients which was published, I think, at the beginning
  23     of 1989, that a tremendous amount of effort from the
  24     centre came behind it in terms of money and in terms of
  25     as it were formal encouragement to the process.

   1        I may be wrong about that because I am not an
   2     expert on this, I have to say, there are others who are,
   3     but that is my impression: that it was something that we
   4     were very much in favour of and benign about, but it was
   5     only after 1989 that we really started to put our weight
   6     behind it in a really tangible and serious way.
   7   Q. And the weight you then put behind it was funding?
   8   A. It was money, yes.
   9   Q. And not only money, but I think a number of circular
  10     letters which prescribed, effectively, that clinical
  11     audit should take place?
  12   A. I must not answer on the detail because I will mislead
  13     you. I was not involved in it very closely, I am not an
  14     expert on it and others are, but certainly my impression
  15     is that a number of central bodies were set up, I think
  16     by the CMO, in order to advance the cause, so to speak.
  17     Money was put into it. I am sure circulars were
  18     issued. Encouragement was given. But certainly the
  19     predominant mode, so to speak, even then I think, was
  20     very much of the idea that we were facilitating and
  21     enabling a process which the profession would have
  22     control of, very largely, rather than something which
  23     was going to be kind of centrally run or centrally
  24     imposed. I think the idea of getting the professions to
  25     do it better themselves was very much the philosophy.

   1   Q. So the funding, obviously, to encourage the profession,
   2     the element of central direction and putting your weight
   3     behind it that you perceived, although you cannot speak
   4     to the detail: how was the weight put behind the
   5     process, apart from the money?
   6   A. As I say, I cannot actually speak to the detail.
   7     Forgive me, I really do not want to sound as though I am
   8     as it were washing my hands of it, I am not, but if we
   9     are now talking about what happened in 1991 and
  10     following, which I think we are, and the implementation
  11     of the NHS reforms, I was not really centrally involved
  12     in any of that. By that time I had left the Management
  13     Executive. The initial part of the period I was in
  14     Scotland. When I came back to England I was Permanent
  15     Secretary. I was not day-to-day routinely involved in
  16     the detail of how the NHS was run, so you will have to
  17     ask other people about that, I think. I would just be
  18     speculating.
  19   Q. Let me then explore what you had in mind by saying "we
  20     put our weight behind it", because it is that word and
  21     the degree of influence or persuasion or coercion or
  22     control, however one puts it, that you saw as being
  23     available to the Department to influence the behaviour
  24     of the clinicians throughout the country?
  25   A. Yes.

   1   Q. That is what I am after.
   2   A. Yes, okay. Well, there would be a whole range of things
   3     that you could do. To some extent I am speculating now,
   4     as I say. This is dangerous; you need to check this
   5     against what actually happened. You put money in it.
   6     Probably you do it by inviting people to bid for funding
   7     that related to a particular project. That is a very,
   8     very visible and powerful way of signalling your
   9     interest in it and of enabling things to happen that
  10     have not happened before.
  11        You certainly handle it at the informal level; you
  12     put your weight behind it in all the conversations that
  13     are had at senior level with the profession; you discuss
  14     it in the joint meetings with the Joint Consultants
  15     Committee; you discuss it with the Colleges and so
  16     forth. You enrol, if you need to, the professional
  17     leaders in the whole enterprise of giving this a higher
  18     priority, and probably, although I do not know what we
  19     did do, you have some kind of organised management
  20     process as well. I mean, maybe you ask individual
  21     health authorities to report on what they are doing in
  22     this field; maybe you even set them targets. I do not
  23     know what we did. You will have to ask others about
  24     that. But there are a whole range of things we can do
  25     which would put weight behind it without, as it were,

   1     imposing a central diktat that "This is how you do it
   2     and you do it the same in every place".
   3   Q. There are one or two aspects of audit so far as it
   4     relates to the UBHT that I want to come back to and
   5     I will do so when documents are available, which are
   6     presently being scanned in.
   7        Before we leave paragraph 6, you say, in the
   8     middle of that paragraph:
   9        "Although much data was available, it was not used
  10     systematically except in limited contexts, and then by
  11     professional organisations."
  12        What did you have in mind in particular?
  13   A. That I was aware that quite a lot of activity was going
  14     on, for example, I think I am right in saying that even
  15     in the mid-1980s and it may be earlier than that, I do
  16     not know, there was a process called CEPOD, the
  17     Confidential Enquiry into Peri-operative Deaths,
  18     which -- I am not sure exactly the process, but it
  19     certainly had its origins in some very enthusiastic and
  20     able people in the profession, who got this started, and
  21     I am not quite sure which professional bodies were
  22     involved, whether it was the College of Surgeons -- it
  23     probably was the Royal College of Surgeons, I think, who
  24     took it up, and ran it, and it progressively got taken
  25     up and more and more people began to participate in it.

   1        Then at some point around I would think the late
   2     1980s, early 1990s, I am not sure when, I seem to
   3     remember the Department actually put quite a lot of
   4     money into it in order to try and as it were take it on
   5     to the next stage of becoming a comprehensive national
   6     system that is related to surgical outcomes.
   7        My understanding is that it was a limited system.
   8     It looked at peri-operative death, I think that means
   9     death within 30 days of operation. It is one aspect of
  10     looking at the quality of surgery. But that is an
  11     example of a professionally run, if you like, process at
  12     that time. It is something that is still professionally
  13     run, but I think now with greater participation, and
  14     certainly greater funding by the Department.
  15   Q. So the professional organisations which you had in mind
  16     were those such as the Royal College of Surgeons?
  17   A. Surely.
  18   Q. If the Royal College of Surgeons or, we in this Inquiry
  19     have heard about the cardiothoracic surgeons, if they
  20     had data which they collected which related to the
  21     Health Service, which it was known to the Department had
  22     been collected in respect of the Health Service, was
  23     there a system or practice whereby the Department also
  24     was given that data?
  25   A. As I say, there were one or two procedures the

   1     Department was involved in and indeed ran in a sense,
   2     like the confidential enquiry into maternal deaths
   3     which, I think I am right to saying -- you really need
   4     to ask others -- involved the Chief Medical Officer
   5     being in possession of all the facts that came out of
   6     such enquiries.
   7        To be honest with you, I do not know the extent to
   8     which the Department received information about, for
   9     example, CEPOD, which was over and above such data as
  10     was published. I imagine these things did find some
  11     kind of expression in publication, in journals and that
  12     kind of thing. Whether the Department received it, it
  13     would not have come to me so I do not know. Whether the
  14     Department received extra information, so to speak, I do
  15     not know. What I do know in general is that this is
  16     a pretty kind of touchy area, and doctors have always
  17     been quite understandably pretty careful about
  18     disclosing results, for all sorts of reasons including
  19     patient confidentiality.
  20        I do not imagine the stuff would have been widely
  21     disseminated.
  22   Q. If you had been asked, whilst you were Home Secretary,
  23     whether you wanted access to such data, would you have
  24     said "Yes" or "No"?
  25   A. I do not think I can answer that in such a general

   1     question. It would depend very much on what data you
   2     are talking about and the context in which it was to be
   3     made available.
   4        But in general, I am sympathetic to the idea that
   5     one wants to move as far as possible towards openness.
   6     This is not an uncontroversial thing to say, I may say,
   7     but I think that is the general direction of movement
   8     for official policy, as I understand it now, and
   9     I believe the Department is progressively trying to
  10     bring more and more information about clinical outcomes
  11     into the public domain.
  12        That has all kinds of difficulties about it; it
  13     is not a straightforward process, both in terms of
  14     confidentiality and in terms of interpretation of the
  15     results. This data can be very, very misleading
  16     sometimes, and it has to be interpreted: why does this
  17     person or this unit have worse results, as it appears,
  18     that way? There may be very good reasons why their
  19     results are worse, such as the obvious one: they may be
  20     doing more difficult cases or they may be -- well, the
  21     same point, I suppose, dealing with a different
  22     catchment population. I can understand why surgeons and
  23     consultants are going to be very sensitive about that,
  24     because it would be very easy for people to be attacked
  25     or pilloried when actually they are doing a very good

   1     job, very conscientiously.
   2        So it is not a straightforward matter, it is not
   3     a matter in which the world is going to change
   4     overnight. My own personal view is that, nonetheless,
   5     the only way to go is progressively towards greater
   6     openness, and that has to be done in the context of
   7     hopefully developing at the same time a greater
   8     understanding, a greater understanding on the part of
   9     the public, and particularly journalists and other
  10     people who write and comment on these things, about the
  11     complexities of it. Otherwise, if it is done in a kind
  12     of simplistic headline-grabbing way, I think you can be
  13     very, very unfair to people. And indeed, not only be
  14     unfair to people, it can have detrimental effects.
  15   Q. Looking back on it historically rather than anticipating
  16     the future, what I was asking you was whether or not
  17     data which underpinned the reports of the various
  18     enquiries into performance of parts of the National
  19     Health Service was actually supplied to the Department
  20     of Health. You said that you do not know that detail,
  21     you are not in a position to know it.
  22        The next question is whether there were systems
  23     for obtaining such data. Is the answer the same: that
  24     you cannot help us with whether there were or whether
  25     there were not?

   1   A. Yes. You are pushing me into areas where my knowledge
   2     was probably always fairly limited, and now my
   3     recollection is very hazy. There was of course
   4     a national system of collecting statistics about the
   5     Health Service. That is presumably still in place. It
   6     did include some data about clinical matters. I think
   7     that would be right to say. That data was received
   8     obviously in the Department, indeed, some of it was
   9     published, but you would have to ask other people about
  10     what use was made of it and what analysis was made of
  11     it. I think this was something that would have been
  12     handled very much on the medical side of the
  13     Department. I would be on really unsafe ground in
  14     talking about it, forgive me.
  15   Q. The third question which followed, or would follow --
  16     appreciating that you cannot say anything as to systems
  17     apart from the general information systems which operate
  18     in the National Health Service about which I can tell
  19     you we have had some evidence -- is if there was data
  20     collected in respect of individual specialties by people
  21     working in and for the National Health Service in
  22     respect of patients treated under the National Health
  23     Service. It might be asked by any observer now, if the
  24     data was not obtained by the Department of Health, why
  25     not? I think the answer you have given thus far is that

   1     it might have been too sensitive an issue for a number
   2     of clinicians, and we are perhaps back to the
   3     clinician/manager interface. Was there any other reason
   4     that might occur to you?
   5   A. I suppose you do not collect or draw in and analyse
   6     data -- because there is no point in collecting it
   7     unless you analyse it -- unless you are going to do
   8     something with it. I suppose that this part of the
   9     thinking on that would be, "Well, can we do anything
  10     useful with it?"
  11        As I have already said a number of times, I think
  12     that the context in the early 1980s at any rate, and
  13     earlier than that, was a different one from the context
  14     now, and I think that one's view of what could be done
  15     with it and what one might want to do with it would have
  16     been different, would have been rather more limited, if
  17     you see what I mean, in what could be done.
  18        But I do not want to give you the impression,
  19     Mr Langstaff, that the Department took no interest in
  20     outcomes. That would not be true. For example,
  21     I remember somewhere in my statement, I certainly do
  22     recollect, for example, having discussions with
  23     a Regional Health Authority. Remember, at the centre we
  24     then had 14 Regional Health Authorities and they were
  25     the bodies with whom we primarily interacted, not with

   1     the 200 or so health authorities. I do remember having
   2     discussions, not me personally, but being in the room
   3     when discussions were being held with a Regional Health
   4     Authority about the record in its region on perinatal
   5     mortality, for example, that this was the region that
   6     had the worst, if you like, figures for perinatal
   7     mortality, the highest number of deaths per thousand in
   8     babies in and around birth, and what the region was
   9     seeking to do in order to get an improvement.
  10        So it was not that we took no interest in these
  11     matters at all, but the interest was limited to a few
  12     key issues; it would not have been comprehensive or
  13     extensive.
  14   Q. I am going to come back to explore the relationship
  15     between Centre, Region and District, or, for that
  16     matter, Trust, at a later stage in the questions that
  17     I want to put to you. Can I show you SLD 2/5 as a means
  18     of focusing some further questions on the reaction that
  19     the Department might have had to the question of
  20     outcomes and so on.
  21        If we can scroll down, please, this is, as you may
  22     gather from the cartoon nature, from Private Eye, issue
  23     797, 3rd July 1992, to put a date on it.
  24        You can see in the second last paragraph on the
  25     left-hand column:

   1        "Mrs Bottomley claims that whistle-blowing through
   2     the correct channels will get results. Staff at the
   3     United Bristol Healthcare Trust, the UBHT, have been
   4     whistling about the dismal mortality statistics in the
   5     paediatric cardiac surgery unit since 1988 (Eye 793).
   6        "Whilst UBHT's Chief Executive John Roylance, the
   7     Royal College of Surgeons and Duncan Nichol, the Chief
   8     Executive of the NHS Management Executive, are all well
   9     aware of the problem, they seem more concerned with
  10     silencing the blowers ..."
  11   A. This would be when? What date is this?
  12   Q. July 1992. It quotes a complaint four issues earlier
  13     about what are described as "dismal mortality
  14     statistics".
  15   A. Okay, so that would be June or something 1992?
  16   Q. That would be March/April 1992. A number of questions
  17     about this: is this something you yourself have ever
  18     seen before?
  19   A. Only as it were latterly, because somebody told me that
  20     this had emerged as an issue. Whether I saw it at the
  21     time, to be honest with you, I do not know.
  22   Q. Did you read it from time to time?
  23   A. From time to time but not regularly.
  24   Q. Did the Department have a Press Office?
  25   A. Certainly.

   1   Q. Was it part of the duty of the Press Office to pick up
   2     reports about the NHS and how they were functioning?
   3   A. Yes, but -- may I explain how I think it worked?
   4   Q. Let me ask you a couple more questions and then by all
   5     means add what you want. Do you know whether they
   6     looked at magazines such as Private Eye?
   7   A. I am pretty sure that the Department took Private Eye.
   8     I mean, this is where I need to explain the system.
   9   Q. Then please explain it.
  10   A. We took, obviously, all the national newspapers,
  11     including the Sunday newspapers, and they were scanned,
  12     I think even in those days we probably used an agency,
  13     but the national press, the dailies or Sundays, would be
  14     scanned by an agency and anything that is to do with the
  15     business of the Department would be extracted, copied
  16     and circulated very widely in the Department, either on
  17     a comprehensive basis, you could have the whole lot
  18     every day, as I did, which was a pretty fat bundle,
  19     usually, or I think you could have a kind of more
  20     limited service that focused on particular topics.
  21        So that is the newspapers.
  22        As for magazines, my recollection is that the
  23     press cuttings service did not cover magazines. It may
  24     have covered just one like The Economist or something
  25     like that, I am not sure about that, but in general the

   1     system for magazines as I remember it is that they were
   2     bought in some quantity by the Press Office or by the
   3     Department, anyway, and then made available to such
   4     people as wanted to read them on a kind of circulation
   5     list. This would be the common system you would have in
   6     any large organisation. That would include the obvious
   7     things like the important medical journals, the Health
   8     Service journal, the Economist, The Spectator.
   9     I think -- I am on oath, so I must say I am not
  10     absolutely certain, but I think Private Eye, but I am
  11     not absolutely certain about that.
  12        Whether you saw it or not, then, in that case, on
  13     the hypothesis that Private Eye was in the list, whether
  14     you saw it or not depended on whether you had asked to
  15     see it. Are you with me?
  16   Q. So are you saying there would be no automatic reference
  17     of a complaint like this to the individuals mentioned,
  18     take Duncan Nicol, for example?
  19   A. In that particular case, as it mentioned him by name, it
  20     is obviously more likely, can I put it that way, that
  21     somebody would read it and notice and mention it to him,
  22     but whether that happened, I have no knowledge. Whether
  23     it actually happened, I do not know. I do not know
  24     whether Duncan ever saw this or whether anybody ever
  25     drew explicit attention.

   1   Q. Would you be able to say what response you might expect
   2     from the Department to a complaint such as this? The
   3     complaint appears to be of covering up statistics which
   4     are available to anyone who asks sufficient questions,
   5     looks at the data, and so on.
   6   A. I am sorry, would you repeat the question?
   7   Q. There is an allegation, it would appear here, that the
   8     NHS Management Executive, at any rate, may be involved
   9     in covering up the poor performance of an NHS unit,
  10     which would be obvious for all to see if they had
  11     examined the appropriate data. That is the allegation.
  12   A. Yes.
  13   Q. How would you expect such an allegation to be treated in
  14     the NHS in the time that you were the Permanent
  15     Secretary?
  16   A. I suppose in general one would expect it to be taken
  17     seriously, but I think it does depend a bit on how it is
  18     made, who it is made by and the context in which it is
  19     made. It is one thing if it is true. I do not know
  20     whether it is true. If it were true that this was
  21     familiar material, so to speak -- I mean, the
  22     implication there is that it is familiar material,
  23     everybody knows about this. If that were true and it
  24     had already been looked at very carefully by people,
  25     then they might be inclined to say, "We already know

   1     about this and we have looked into it" and so on and so
   2     forth.
   3        That is why I say it depends on the context in
   4     which it arose. Obviously if it was entirely new and
   5     actually was not, contrary to the impression given,
   6     known before, then that is obviously a different
   7     situation.
   8   Q. What would you expect to happen in that different
   9     situation?
  10   A. In an ideal world, maybe you would do something about
  11     it. I cannot see the whole page here, Mr Langstaff,
  12     but --
  13   Q. Do you want to scroll down?
  14   A. I am making a general point. I think you will find
  15     there are probably 10 or 12 stories there. Private Eye
  16     comes out once a fortnight, I think. There is a lot of
  17     other media comment as well, not only in the printed
  18     press but in the broadcast press. I do not think the
  19     Department then, or subsequently, would aim to follow up
  20     each and every single story in the media alleging
  21     something wrong in the NHS as a kind of routine.
  22     I think it would be something to which people in the
  23     real world would have to apply judgment as to whether
  24     they thought it was something that was a true bill or
  25     was likely to be a true bill and needed to be followed

   1     up in a serious way.
   2        But as I say, all this is hypothesis, because I do
   3     not know whether we were aware of all this before or who
   4     saw it.
   5   Q. It is useful to ask you because you have, better than
   6     anyone, I suspect, from your position, a view and
   7     perspective which is informative, even if you cannot
   8     yourself deal with the exact facts.
   9        It is that which we are exploring. I appreciate
  10     that you did not know of this particular episode, but
  11     what you are saying is that a judgment would have to be
  12     made by someone as to whether to follow it up or not in
  13     the real world; is that the way you put it?
  14   A. Yes.
  15   Q. And if an allegation such as this were to be followed
  16     up, how, in 1992, do you suspect it would have been
  17     followed up?
  18   A. Gosh, that is a very broad question. I will answer in
  19     a general way, if I may. I really do not want to get
  20     into the details of this case which I do not know about,
  21     but let us take as a hypothesis that an apparently
  22     serious allegation that may well be well-founded comes
  23     in front of a Chief Executive or some senior
  24     Departmental official. He or she would ask the relevant
  25     person in the Department to follow it up with local

   1     management. That is the only way you could do it,
   2     I think, to ask the local people. You might do it
   3     through the Region or you might do it direct with the
   4     local Health Authority or, indeed, in this case
   5     I suppose the Trust. I think what you would do is you
   6     would get on the telephone or write a letter and say
   7     "This allegation has been brought to my attention.
   8     What do you have to say about it?" Then obviously you
   9     evaluate that and take it from there.
  10   Q. To finish perhaps this passage of the questions I have
  11     to ask you, may I invite your response, if you feel able
  12     to respond, to the allegation which has been made during
  13     the course of this Inquiry that the Department of Health
  14     was involved in a cover-up of the Bristol figures. That
  15     is the allegation, relatively unspecific, and it does
  16     not descend to names, but as the Permanent Secretary
  17     between 1992 and 1997, you are, I think, the appropriate
  18     person to ask for a response as far as you are able to
  19     give one.
  20   A. My only response is, I have absolutely no knowledge of
  21     that. In so far as I understand what "cover-up" means,
  22     I think it is a pretty scandalous allegation and I would
  23     be very surprised if it was true.
  24   Q. Moving from that, if I may, to the internal organisation
  25     of the Department, we have spoken of a number of

   1     committees and the Advisory Group. Can you help as to
   2     how the individuals who were appointed to such a group
   3     came to be appointed and how it was that other
   4     committees important in developing and maintaining
   5     health policy came to have the constitution in terms of
   6     individuals that they did?
   7   A. If you are asking me, Mr Langstaff, how the Supra
   8     Regional Services Advisory Group was chosen --
   9   Q. That is an exemplar of the general, which is who was it
  10     who determined who sat on the various committees, as
  11     individuals?
  12   A. I cannot answer for the Supra Regional Services Advisory
  13     Group in particular. In general, members of an Advisory
  14     Group to Ministers would be appointed by Ministers, on
  15     the advice again of officials. I suppose classically
  16     the way you would approach an issue like that when you
  17     were setting up such a committee is that you would think
  18     about the nature of its work and therefore the kind of
  19     people that you would want to have on it who would be
  20     most likely to be able to contribute to the work. You
  21     might think about various groups or interests that might
  22     be represented. I do not mean "interests" in the sense
  23     of being self-seeking but simply interest groups like,
  24     in this case, obviously you would want some kind of high
  25     level professional involvement from the Royal Colleges

   1     or the professional bodies, at any rate, that were
   2     involved; you would want in this case some kind of NHS
   3     management involvement, indeed, the Chair in this
   4     particular case, I don't know whether it is always, but
   5     certainly for a long time it was a Regional Chairman.
   6     You might well want -- I do not know whether there was
   7     in this case -- some kind of nursing involvement and so
   8     on. So you would think about the different groups.
   9        Then you would cast about, if I can put it that
  10     way, for a suitable list of candidates for membership
  11     and you would do that by, for example, taking advice
  12     from senior medical staff who in turn would no doubt
  13     consult in the profession with the Colleges and so on,
  14     and you would draw together a list of names. You would
  15     then put your recommendations to Ministers.
  16        That is a broad description of how you would set
  17     about setting up a group like this.
  18   Q. So the names, by means of the process you have
  19     described, come through the Department. So far as the
  20     Departmental representatives, the Medical Officers, are
  21     concerned, people such as Dr Halliday in the
  22     Supra-regional Services Group, how would they come to be
  23     on the committee? Plainly someone has to nominate or
  24     appoint?
  25   A. I do not know, but I do not think Dr Halliday was

   1     a member of the committee, if you will forgive me.
   2     I think he was the Medical Secretary. So his role in
   3     relation to the committee would, so to speak, come with
   4     the rations. He was responsible for the subject that
   5     the committee was interested in, and therefore, by the
   6     nature of his duties, he would be associated with his
   7     work. Whether he would actually be the Medical
   8     Secretary is obviously a matter that the Chair and he
   9     would sort out between them. But it came with his job,
  10     so to speak, to be involved in the work of that
  11     committee.
  12   Q. Plainly, when one looks at the professional men or women
  13     involved in the various committees, from what you said
  14     the Department would look for someone who carried
  15     a certain amount of clout, prestige, that would
  16     inevitably, one suspect, be a busy, active person in the
  17     profession or organisation whose interests you might be
  18     thought to represent?
  19   A. You might want clout and prestige. I do not think
  20     I would use those words. You certainly want competence
  21     and knowledge. That is what you want above all else.
  22     You want to have people who are competent to contribute
  23     to the committee.
  24   Q. Is there perhaps a problem on occasions in that those
  25     people who appear, and undoubtedly are highly competent

   1     and highly valued for their competence, may find
   2     themselves on quite a number of committees by reason of
   3     that fact?
   4   A. I think that does happen, yes.
   5   Q. Is there any sense that might detract from their ability
   6     purely by function, numbers and time, to make an actual
   7     valuable contribution to the work of each?
   8   A. I suppose that could happen. I think you have to rely
   9     on their good sense and to some extent you have to rely
  10     on the good sense and the integrity of the people you
  11     appoint to give it a fair allocation of time and effort,
  12     although it is not unknown -- I do not know whether it
  13     happened in this case -- for a Chairman of a committee
  14     to decide that it would be a good idea to dispense with
  15     the services of a committee member,
  16     because they are not giving it the time or commitment or
  17     whatever. So it is not purely in the hands of the
  18     individual, it is also down to the Chairman and
  19     Secretariat to look at things like attendance and
  20     obviously if people come to committees and they have not
  21     read the papers and all that kind of thing, you expect
  22     to take that into account. It is all part of being
  23     a competent member of a committee.
  24   Q. I said I was coming back to the question of audit once
  25     documents had been scanned in, and at the same time

   1     I want to explore with you the way in which the centre
   2     operated through the Regions who you say were your first
   3     point of contact, while there were Regions, and how the
   4     issue of accountability of the District, subsequently
   5     the Trust to the Centre, was maintained and organised.
   6        Can I do it in this context: if we go, please, to
   7     HA(A) 167/1, you will see that we are looking at
   8     a document called "Meeting and Improving Standards of
   9     Health Care", South Western Regional Health Authority
  10     1994."
  11        It is in relation to clinical audit. It says that
  12     underneath the shading.
  13   A. Do we know what the context is of this, Mr Langstaff?
  14   Q. This is an annual report from the Region about clinical
  15     audit. If we turn to page 3, you will see the
  16     distribution list.
  17   A. Fine.
  18   Q. If we go to page 6 in the introduction, we see that the
  19     report intends to account to the Department of Health
  20     for progress in the evolution of clinical audit and
  21     enhancing and improving patient care and outcome.
  22   A. Yes.
  23   Q. That is in accordance with EL 93/34.
  24   A. That was one of those circulars that you referred to
  25     earlier.

   1   Q. Yes, so what appears to be the system is that there is
   2     a circular which comes out from the Centre which says
   3     "account to us for clinical audit" and this is the
   4     method of accounting.
   5        Just pausing there for a moment, so far as the
   6     Centre was concerned, did it require Regions to account
   7     to it for their performance or their management in
   8     a number of specific respects from the early 1980s until
   9     the late 1990s? You are nodding.
  10   A. Yes.
  11   Q. A nod does not go down on the transcript which is why
  12     I have to say that. The system worked that the Centre
  13     would require, whether by means of a letter such as
  14     referred to as EL 93/34 or otherwise, the Region to
  15     account in a formal way wherever it was felt necessary?
  16   A. Yes.
  17   Q. What was the intention that the Regions should do so far
  18     as the District comprising the Region were concerned?
  19   A. I do not know how this particular exercise went, so is
  20     that a general question?
  21   Q. It is a general question.
  22   A. Obviously it would depend again on the subject and how
  23     it would be best managed. There would be some things
  24     which a Regional Health Authority might be expected to
  25     handle on its own; not perhaps many, but a few.

   1     Obviously on those it would account as it were on its
   2     own account.
   3        But most of the issues on which the Department
   4     sought to monitor achievement would be things that were
   5     actually local and the Region would therefore have to
   6     transmit the policy and the imperatives, so to speak, to
   7     the local Health Authority or whatever, and would then
   8     ask them to account back to the Region for what they
   9     were doing, and then the Region would in turn account to
  10     the Centre.
  11        So it would be a rolling on process of down the
  12     line and then back up the line, so to speak.
  13        That is broadly how I would expect it to work.
  14   Q. The links of the chain down the line transmit the
  15     policy, the links back up transmit the results, or
  16     whatever it is?
  17   A. Broadly that would be right, yes.
  18   Q. So if there is a problem in achieving the policy at
  19     a local level, say in an individual hospital, the first
  20     point of accountability beyond the hospital is going to
  21     be the District, is it, back in the 1980s?
  22   A. Back in the 1980s Districts were, as you know,
  23     responsible for the management of the individual
  24     hospitals, yes.
  25   Q. And the District responsible to the Region?

   1   A. Correct.
   2   Q. And the Region to the Centre?
   3   A. Correct.
   4   Q. At the time that this was written, plainly post 1993,
   5     1993/94, there were Trusts. What was the process so far
   6     as Trusts were concerned?
   7   A. I was not deeply involved in this myself, so I think you
   8     would do better to ask others who were, but my general
   9     understanding is that the Regions would also have lines
  10     of communication to Trusts and could certainly hold them
  11     to account for the achievement of certain aspects of
  12     their performance, although I think it is true to say
  13     that the relationship between Regions and Trusts was
  14     principally about financial management and targets.
  15   Q. If we turn to page 8, we see that the Region here were
  16     saying as an "NB" at the foot of the page that the
  17     report had been produced by the Regional Clinical Audit
  18     Co-ordinator on behalf of the South Western Regional
  19     Health Authority as part of the annual accounting and
  20     monitoring process to the Department of Health?
  21   A. Yes.
  22   Q. So the intention is that here there is money for audit,
  23     given centrally. The Region are responsible for that in
  24     distributing it or ensuring its distribution amongst the
  25     Trusts and they account back to the Department of Health

   1     so that presumably the Department of Health may monitor
   2     the way in which the funds have been spent?
   3   A. Yes.
   4   Q. Having established that that is probably the process
   5     that we see, can I invite you to look at some of the
   6     specifics? I appreciate you will not have seen this
   7     document before, but it gives rise to questions which
   8     you will see emerging as we go through one or two of the
   9     pages.
  10        Can we have a look at page 37? Can we scroll down
  11     so we get "Staffing" on the screen? "Percentage
  12     Expenditure of Total Available Funds (Staffing)", and
  13     the Trusts are all identified. Perhaps if we just
  14     rotate through 90 degrees, we can read the Trusts, and
  15     you can see that of the Trusts identified, the fourth
  16     down is the UBHT. And the percentage of money spent on
  17     staffing, if one were to read the graph as a graph to
  18     which the UBHT had responded, would be nought per cent,
  19     which is plainly nonsense. The only interpretation one
  20     can have of this is that the UBHT did not supply the
  21     available data to the Region for anything sensible to be
  22     put on the graph.
  23        I have drawn that to your attention because I will
  24     show you what follows in the report. It will be
  25     something which, because this document is new, the Trust

   1     will be invited to respond to from their perspective in
   2     due course.
   3        But if we can go to page 44 and just scroll up,
   4     please, so we can see what we are looking at, this is
   5     "Activity by Trust, 1993/94" of those reported. There
   6     are attendance rates at medical audit meetings, and
   7     again one can make the same comment. It looks as though
   8     what has happened is that the UBHT simply has not
   9     reported to the Region.
  10        Shall we go through, having looked at that --
  11     I think we can scroll back. HA(A) 167/36. Expenditure,
  12     total budget. There is nothing against UBHT. Page 38
  13     [HA(A) 167/38]. Nothing against UBHT in either of the
  14     graphs. HA(A) 167/39: the same point. HA(A) 167/40:
  15     there are two graphs. Nothing from UBHT in either.
  16     HA(A) 167/41: nothing there at the top, nor at the
  17     bottom.
  18        So an absence of information, it would appear,
  19     supplied by the United Bristol Healthcare Trust to the
  20     Region in order to account to the Department of Health
  21     centrally so that the Department of Health centrally can
  22     monitor what has happened with the expenditure of funds.
  23        So the expenditure of funds themselves, the
  24     document is helpful, at page 72 we can see there in
  25     appendix 2 clinical audit allocations, 1994/95?

   1   A. Is that the same year?
   2   Q. It is the next financial year. You have seen the
   3     results for the year 1993 to 1994. This is the
   4     allocation for 1994 to 1995. The United Bristol
   5     Healthcare Trust, if one reads across the top line --
   6     perhaps we could have that highlighted?
   7   A. If I may interrupt, what that table seems to be showing
   8     is that these are the actual specific figures for UBHT
   9     for the 1993/94 commitments, does it not?
  10   Q. You are right, I am grateful for being corrected.
  11   A. It looks as if there is a global allocation for Bristol
  12     and District in the right-hand column, 737, but not
  13     broken down between individual Trusts within that global
  14     figure.
  15   Q. I think it is. Is that not the figure we get from 308.8
  16     in the top line?
  17   A. No, that is still under the heading "1993/94
  18     commitment".
  19   Q. So the money which has been committed to audit for
  20     1993/94 for UBHT would appear to be œ308,800.
  21   A. I see what you are getting at.
  22   Q. In other words, the funding for the year 1993 to 1994 in
  23     respect of which the report is reporting would appear to
  24     show that of the Trusts in the Bristol and District
  25     area, the UBHT was the biggest consumer or had the

   1     biggest funds committed to them?
   2   A. Yes, it looks like that. It looks as though they had
   3     getting on for half the money.
   4   Q. In fact, if one casts an eye just down the page, of the
   5     total clinical audit allocation, they have more than any
   6     other individual Trust which is identified on the page?
   7   A. Yes.
   8   Q. So the picture would seem to be that UBHT were getting
   9     the most money, or had the most money committed to them,
  10     and they were simply not providing any data or details
  11     to the Region for the Region to report to the Department
  12     of Health.
  13        A number of questions. First of all, do you know
  14     whether this was or was not typical of Trusts throughout
  15     the country, let alone this region?
  16   A. No. I mean, I have no knowledge of any of this at all.
  17     I hope it was not typical, but I do not know the
  18     circumstances. I do not know why there was this gap in
  19     the data.
  20   Q. I am asking you to comment on something which is
  21     a specific case, and it is really as a springboard to
  22     asking you a number of questions about the system.
  23        What one would pick up from this is that unless
  24     there is some explanation, there has been a lack of
  25     co-operation by the United Bristol Healthcare Trust to

   1     providing information which is necessary for the
   2     Department of Health to have in order to monitor the
   3     expenditure of its funds?
   4   A. It looks like it.
   5   Q. In such a case, obviously one would want an
   6     explanation. From whom would the explanation have been
   7     sought so far as the Department was concerned?
   8   A. If it was sought, it would have been sought from the
   9     Region, I think.
  10   Q. So the Department have said, "Why do we not have the
  11     data from Bristol; you have shown us an absence here of
  12     any data, and yet this is the biggest spender amongst
  13     your Trusts. What is the reason for that?" Something
  14     of that sort?
  15   A. Something of that sort, but I am making an assumption
  16     that this report we have in front of us from this
  17     particular region to the Centre was structured the way
  18     it was in order to respond to some kind of central
  19     pro forma, or whatever. I do not know whether it was
  20     like that or whether the Department simply said to
  21     Regions, "Send us a report in whatever form you find
  22     helpful", or whether there was a highly structured
  23     accounting exercise, I do not know. Certainly if it
  24     were that, then I think the assumption would be that you
  25     would want the data from everybody, although if I may,

   1     I would make the obvious comment that what I think the
   2     Department would be looking for in this would not
   3     necessarily primarily be the performance of individual
   4     Trusts or the lines for individual Trusts. What you
   5     would be looking for was an aggregated picture for the
   6     Region or probably for the whole country about some of
   7     the answers to some of the questions that these data
   8     were intended to provide: what proportion of the money
   9     was being spent on this; what proportion of the money
  10     was being spent on that.
  11        The Department's way of looking at this would not
  12     be to say "Our primary concern here is to make sure that
  13     the performance of each and every Trust in the country
  14     is up to scratch or has to be of this kind or that
  15     kind"; what we would have been seeking, I think, is
  16     a kind of global picture of what is happening throughout
  17     the country. For example, the obvious questions that
  18     occur to one, I do not know whether this was in people's
  19     minds, but how was the money being used, how much
  20     percentage on this, how much percentage on that.
  21        The question in your mind in doing this would not
  22     be: is UBHT or is any other particular Trust --
  23     remember, there are hundreds and hundreds of Trusts --
  24     doing this or, you know, is it doing it well or badly.
  25     I think you were trying to build up a composite picture;

   1     it is about the kind of strategic management of the
   2     exercise; it is not about holding individual Trusts to
   3     account from the centre.
   4   Q. Can I deal with two matters which you have raised in
   5     that lengthy answer? If we go back to page 7 of this
   6     document, 167/7, we see the context of the report,
   7     "Reporting requirements". It indicates what it
   8     includes in the first bullet point. The third bullet
   9     point down:
  10        "Towards the end of 1993 the minimum data set was
  11     issued by the Department of Health as the basis for
  12     local arrangements for reporting on audit activity."
  13   A. Fine. It sounds as though it was a standard national
  14     format.
  15   Q. The next bullet point if we go down to that --
  16   A. This is still from the South West document, is it?
  17   Q. This is all from the South West document. Can I take
  18     you away from the South West document, because I do not
  19     want anything I say to be picked up unfairly. If we go
  20     to UBHT 28/23. You can see that the format is set out.
  21     This is EL 93/34.
  22   A. This was the circular that you referred to that called
  23     for this?
  24   Q. That is right. You can see what annual reports should
  25     cover. The details are set out. Shall we scroll down

   1     so you get a flavour of it? By all means stop the
   2     scroll if you think that you want to look at anything in
   3     greater detail. Can we go across to the next page,
   4     UBHT 28/24? You can pick up the bold headings to give
   5     you an idea of what is being mentioned.
   6        Again, so I do not mislead or give a wrong
   7     impression, can we look at UBHT 66/316? This is the
   8     start of a document. I am going to take you to
   9     a particular page in it.
  10   A. It is a different report, is it?
  11   Q. It is a different report. It speaks for itself. Can we
  12     go to page UBHT 66/322? Can we scroll down underneath
  13     "Expenditure"?
  14        An explanation is given there for why it is that
  15     UBHT has not reported:
  16        "Local distribution of funds has varied. For the
  17     purposes of the fo