Annex A > Chapter 11 - Referrals > Referrals to Bristol from South Wales > Evidence of influences on patterns of referral from South Wales
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Evidence of influences on patterns of referral from South Wales
148 A number of factors appear to have influenced referral patterns from the South Wales catchment area. One event was the establishment of the Paediatric Cardiac Unit in Cardiff in 1991. Before considering the impact of the establishment of this centre, the influences on referrals from South Wales prior to 1991 are considered.
Funding and resources pre-1991
149 In relation to the funding of referrals from Wales, Mr Nix told the Inquiry:
`Bristol and Weston HA also provided paediatric cardiac surgery and cardiology services to South Wales. However, the level of service provision was increasing annually and the Welsh Office wanted to provide a service in Cardiff. In 1987/1988 there were discussions with the Welsh Office about providing Paediatric Cardiac Surgery which did result, because of delays in reaching agreement, in the sending of letters to each Health Authority, stating that services would be restricted if funding for children over 1 year old was not provided. This was because children over 1 year old were not within the Supra Regional remit and were therefore the responsibility of the Health Authorities, whereas, those under 1 year old were the responsibility of the Welsh Office/DHSS. The SWRHA was present at the majority of the meetings and kept informed of discussions. The Welsh Office did, I recall, fund some additional workload as an interim measure with a view to setting up a service in Cardiff.' [155]
`So as to protect the service to the South West, the HA asked the Welsh HAs for money to pay for the increased work for the over 1 year of age group. The Welsh Office was asked for additional money for patients under 1 year old, as this age group was the responsibility of the Welsh Office in a similar way to DoH being responsible for Supra Regional services for the under-1s for England. There were a number of meetings with the Welsh Office (Mr Gregory). ...' [156]
151 Mr John Watson [157] told the Inquiry:
` ... there was an issue in respect of the possible expansion of cardiac services in general, from which there developed serious concern about funding of referrals from South Wales ... The history for this was that the paediatric cardiologists would conduct "outreach" clinics in South Wales and would refer cases to Bristol, leaving it to others to sort out the funding for this work. I became involved in referral issues in 1986 when it became apparent that the number of referrals from South Wales to Bristol exceeded the resources available (and by this I mean both finances and staff). ... we entered into discussion with the Welsh Office to try to ensure that they were paying for the services that they were receiving. It was felt that we needed to reach agreement with the referring bodies before the situation got out of hand.' [158]
`Irrespective of any such processes performed by us as managers, the decision on whether or not to refer a case to Bristol would essentially rest with the clinicians. With this background we had to address a very real problem of lack of funding of the Welsh referrals, to a point where a decision had to be made, probably by the district management team, about whether or not more patients could be taken until the funding position was sorted out.' [159]
153 Mr Watson referred to discussions and correspondence, particularly that passing between himself and the Welsh Office in 1987 in relation to the funding for adult and paediatric cardiology referrals. He referred to a note of a meeting he had with Dr Baker, [160] Miss Stoneham [161] and Mr Nix in May 1987. [162] The note records:
`It was reported by Mr Nix that we have funding for services to adults and children under the age of one year. It was also noted that the expansion to 670 cases per annum excludes the Welsh position, other than Gwent. Mr Nix and Miss Stoneham indicated that they were in the process of ascertaining the maximum number of patients who could be treated within the resources which would be available ... It was agreed that it would be necessary to put some constraints upon the medical staff with regard to where referrals could be accepted from if the services were to be maintained within the funds available. Dr Baker agreed to write to the clinicians involved.'
154 Dr Baker wrote to Dr Joffe, Dr Jordan, Mr Wisheart and Mr Dhasmana on 8 May 1987. In the letter he referred to:
`... considerable uncertainty and confusion over the nature of the cardiological and cardiac surgical response that those in Wales wish to receive. As you may be aware, several London hospitals as well as Southampton, have cardiologists who are active in holding clinics in South and Mid-Wales and referring patients to their own centres for cardiac surgery. Unless the Welsh Office and the constituent authorities decide where they wish to spend their resources and organise the referral patterns through the relevant cardiologist, then we cannot be confident about the volume of service which will be required from our units here in Bristol. If this is not agreed, then we cannot sensibly determine the implications for our services in terms of space and staffing nor can we make appropriate charges upon the Welsh Office or any other DHSS funding source to cover the costs of the service.
`... Until we have formal arrangements with the Welsh Office and individual health authorities, I do not think that we should be undertaking any services to Welsh patients other than to neonates and infants from Gwent Health Authority. Even with Gwent HA we do not have full formal agreements, although I know that the DMO [District Medical Officer] from Gwent is anxious to establish such agreements. This can probably proceed and we can make sure that resources are covered appropriately including travelling time. I am aware that there have been some informal visits to West Glamorgan and Dyfed Health Authorities, but I must advise that until the matters which I have raised above are settled ... these unresourced services should not continue.
`I have been careful to indicate in all my communications that we are most anxious to assist South Wales and the onus is upon them to get their house in order. Unfortunately, I learn that there are mounting political pressures to limit any out of Wales cardiological and cardiac surgical services.' [163]
155 Mr Watson told the Inquiry:
`Whilst the assessment throughout 1986/1987/1988 of the disproportionate numbers of referrals to resources was going on, we still got new cases in. Throughout that time, from a management perspective, it remained the view that we could not manage the patients at that continuing rate ... the situation at the BRI, with regard to resources and the Welsh issue, continued for some time. It was not until 1989 that funding deals were agreed with the Welsh Office.' [164]
156 In September 1987 Dr Baker wrote to Mr Watson. [165] The letter referred to a forthcoming meeting between the Welsh Office and health authorities in South Wales to discuss cardiac services. Dr Baker asked Mr Watson to assist in preparing an estimate of the service that Bristol could generate in the future. In the letter, Dr Baker wrote:
`I have received a request from Dr Skone of South Glamorgan Health Authority to undertake 50 coronary bypass procedures [166] for patients from their health authority. I am aware that our own services have been slowed by the absence of James Wisheart recently, but I realise also that we are trying to progress some cases from our waiting list through facilities in London. Can you advise me whether you wish to entertain any number of these adult cases from South Glamorgan. Regarding our waiting list initiative, I did write to Gerald Keen indicating that he maximises the flow of patients to London during James Wisheart's absence. He has replied indicating that he himself has a very short waiting list, that Mr Dhasmana has referred nine cases, and they await James Wisheart's return for cases to be progressed from his waiting list.'
157 On 2 November 1987 Dr Roylance wrote to Professor Gareth Crompton, Chief Medical Officer for Wales. [167] This letter was centrally concerned with paediatric cardiac referrals from Wales. Dr Roylance wrote:
`It seems that until now there has been a somewhat ill-defined and underfunded referral pattern from the Welsh District Health Authorities. Referrals from Gwent Health Authority are part of a recognised supra regional service for infants and neonates and this service is funded appropriately. There are referrals also for children above the age of one and these referrals are not funded. Clinicians in other health authorities in South Wales have been anxious to have the assistance of our cardiologists, Dr Jordan and Dr Joffe and a number of clinics have sprung up in West Glamorgan, East Dyfed and Pembrokeshire Health Authorities which are visited by these cardiologists. The referral pattern which is emerging from these authorities is unfunded presently. Officers of South Glamorgan Health Authority are considering the future pattern of their referrals and the extent to which they may wish to use services in Bristol. Liaison and any further referral patterns from Mid-Glamorgan Health Authority are uncertain.
`It is apparent that the current volume of our services has outstripped the resources available for their operation and it has been necessary to redress this situation. It would appear that in 1985 our services were funded adequately and that it is since that year that unfunded growth in the services has taken place. It has been necessary therefore to recognise these facts and to discuss with individual health authorities in South Wales the pattern of referrals that has emerged since 1985, the intention to continue the pattern and the funding required to undertake the service. It is understood that for neonates and infants supra regional funding arrangements can be made between the Welsh Office and the DHSS. Referrals for children in other age groups is not covered by any formal arrangement as for cross boundary flow adjustment. It has been necessary therefore to consider some form of direct charging for services with individual health authorities.'
158 The letter to Professor Crompton enclosed copies of the letters sent to the chief administrative medical officers of DHAs in South Wales [168] on the same day. These letters set out the number of referrals Bristol would accept from each DHA, based on its 1985 figures. In these letters Dr Roylance wrote:
`As you are aware, we have been pursuing for some time with the Welsh Office the need to clarify arrangements for the referral from Wales to Bristol of children requiring cardiology or cardiac surgery services. We still seem to be some way from reaching a longer term agreement and are now encountering considerable difficulties because the number of referrals is outstripping the resources available.
`It is therefore our intention to restrict the number of referrals we can accept to the number of referrals accepted during 1985 when we believe the service was funded adequately, unless arrangements are made regarding funding with those authorities who wish to refer patients in excess of these numbers. Neonatal and infant cardiology and cardiac surgery services can be funded as supra regional services through the Welsh Office and the DHSS directly if future workloads are forecast ... On advice from our cardiologists and cardiac surgeons, the rate of admissions and procedures for children (infants in parenthesis) per million total population are as follows: Admissions 150 (65), Catheterisations 75 (35), Closed operations 30 (20), Open operations 35 (12).'
159 Each letter went on to apply these rates to the particular district and to set out the actual number of referrals which would be accepted by Bristol.
`I regret having to pursue this type of approach whilst being aware that this matter is under active discussion at the Welsh Office with professional staff in Wales. It is certainly not our intention to put undue pressure on those who have the difficult task of finding the longer term solutions to the problem. However, in common with many other health authorities, we are faced with ever increasing demands within a relatively static resource base. The inevitable consequences of allowing continued development of unfunded work from outside the region is to produce a deleterious effect on the services we can provide to the population in our own district.'
161 In December 1987 Mr Watson wrote to Mr Dhasmana, Mr Wisheart, Dr Joffe and Dr Jordan, enclosing a copy of a draft letter he intended sending to the Welsh Office regarding referrals. [169] In the letter he stated:
`Since we met and discussed this subject, various attempts have been made to make progress and I feel that this firmer action is needed. Hopefully, it will be possible to meet representatives from Wales early in the New Year and reach some agreement on funding.'
162 That month Dr Roylance wrote to Mr Owen, Director of the NHS in Wales: [170]
`As you are no doubt aware, on 2 November 1987 I wrote to Dr Crompton, Chief Medical Officer for Wales, regarding children's cardiology and cardiac surgery services for Wales. I understand that this matter has now been referred to yourself. Since that time we have not received a clear response from yourself and, unfortunately, the situation within this district is becoming increasingly difficult and it is therefore necessary to take some action on the matter. We have now decided that as from 1 February 1988 we are unable to receive any new patients aged over 1 year from Wales. I should emphasise that although no new cases in this category can be accepted until agreement on appropriate funding is reached, I would anticipate that in the case of children under the age of 1 year there should not be difficulty with reaching agreement via the DHSS for supra regional funding.'
163 In January 1988 Dr Baker wrote to Mr Watson, [171] enclosing correspondence from Mr Gregory [172] and Professor Crompton: [173]
`Our conclusion might be that the Welsh like writing letters and find it difficult to make decisions. ... There seems to be some confusion about their future plans in so far as they talk of a new paediatric cardiac unit to be built in Cardiff with work expected to begin in 1988 whilst Dr [Professor] Crompton's letter indicates that there is still some uncertainty as to the nature of this unit and where it will be located ... In spite of the Welsh efforts to reassure us I am sure that you will feel that we are still dealing with under funded over referrals of Welsh cases to BCH/BRI and I would have thought there were grounds for proceeding with the letter we composed for John Roylance.'
164 Of this correspondence Mr Watson said:
`It can be seen here that Dr Ian Baker was recommending in January 1988 that we should stick to our guns in terms of limiting the referrals. The clinicians would have been generally unhappy about this as they were looking to expand the Department. There was discussion with the cardiologists who had direct input ... naturally they were quite frustrated as they simply wanted to treat the patients.' [174]
165 Negotiations with the Welsh Office continued during 1988. It was during this period that paediatricians in West Glamorgan approached Dr Joffe to take over an `outreach' clinic at Bridgend previously undertaken by Dr Hallidie-Smith. Dr Baker wrote to Dr Mason, SWRHA Regional Medical Officer: [175]
`The facility with which the Welsh Office and its health authorities serve their populations with English based cardiologists is amazing. John Watson however, the Unit General Manager responsible for cardiac services here feels that whatever is agreeable on the professional networks must have the agreement of the Managers concerned. His position as stated previously is one of wishing to curtail all services to South Wales until he is compensated appropriately for the services he renders. ... matters are clearly getting worse rather than better.'
166 In July 1989 Mr Watson wrote to Mr Gregory. [176] The letter, headed `Cardiac Services for Wales - Children Over 1 Year', confirmed that agreement had been reached for funding referrals for the year commencing 1 April 1989, with discussions for funding for the following year planned to take place in December 1989. The letter recorded:
`Based on advice from our cardiologists and surgeons, the expected total referrals is 75 cases. The basis of the charge will be the number of cases over 28.'
1991 onwards
167 The Paediatric Cardiac Unit at University Hospital Wales, Cardiff, admitted its first patients in June 1991. [177] Once the Cardiff unit was established, the Welsh Office sought to encourage referrals to it. Professor Crompton told the Inquiry:
`... the most important factor from 1991 on in Cardiff was the huge commitment of time that the paediatric cardiologist, with support from the others in his team, made in the visiting and the revisiting, and the persistent seeking of trying to influence the District General Hospital paediatricians in Wales to give the Cardiff centre a chance to show what it could do, if I can put it like that. They were very assiduous in doing that.' [178]
168 Once the Cardiff unit was established, the Welsh Office ceased to fund centrally the referral of paediatric cardiac cases to Bristol. Mr R Williams, Assistant Director, Health Services Division, Welsh Office, outlined this change of policy in a letter to the general managers of East Dyfed, Gwent, Powys and Mid, South and West Glamorgan Health Authorities:
`Since the new paediatric cardiac unit at UHW will be centrally funded to provide a service throughout South and Mid Wales, it is proposed that central funds will cease to be available for the referral of new patients to Bristol and Weston Health Authority for paediatric cardiac services once the paediatric cardiac unit at UHW becomes operational. It would, therefore, fall to individual health authorities wishing to continue with current arrangements to contract with, and fund from their own resources, Bristol and Weston Health Authority in respect of any new patients referred to that Authority once the paediatric cardiac unit at UHW comes into operation.' [179]
169 Mr Gregory told the Inquiry:
`In February 1991, the Welsh Office wrote to the six relevant South and Mid Wales Health Authorities advising them of the arrangements which would apply to the central funding of paediatric cardiac services, and to seek advice in quantifying continuing reliance on Bristol in financial year 1991/92.' [180]
Referral to cardiologists
170 The Inquiry heard evidence that referrals to Bristol increased in the period to 1991, and that the establishment of the Cardiff unit in 1991 did not lead to all patients within its catchment area in South Wales thereafter being referred to it.
171 As with the referrals from the South West of England, the Inquiry heard evidence that the contact between referring paediatricians and cardiologists was a key influence on the pattern of referrals. Both during the period 1984 to 1991 and afterwards, relationships between paediatricians and cardiologists were a significant influence on referral patterns from South Wales.
172 Mr Gregory said: `... up to the present day, there are referrals out of Wales of children who, when the unit was fully operative, could, but for clinical preference, have been treated in Cardiff'. [181]
173 Mr Gregory told the Inquiry that a change in referral patterns occurred in 1987, because:
`a) The premature death towards the end of 1986 of Dr Leslie Davies, the well respected cardiologist who saw the vast majority of the young patients referred to the Cardiff centre in what was largely an adult cardiac practice, created a crisis in the local service in South Wales.
`b) The specialties of cardiology and cardiac surgery in the UK by this time were noticeably understaffed to meet the demands of the population for treatment ... The London Centres, in particular, found it less easy to accommodate the Welsh referrals within desirable timescales for treatment.' [182]
174 Professor Crompton explained how referring paediatricians in Wales responded:
`Welsh paediatricians responded by arranging for additional visits by other cardiologists to their hospitals and we see Bristol and Southampton based clinicians visited South Wales on a regular basis. Whilst patients from the Royal Gwent Hospital, Newport and Nevill Hall Hospital at Abergavenny had traditionally referred to Bristol, we now see others, but not all in South Wales using the Bristol centre.' [183]
175 Mr Gregory was asked for his views as to why children from South Wales were referred to London hospitals. His evidence included this exchange:
`Q. For what reasons do you understand children were referred to Brompton, the National Heart Hospital or Great Ormond Street?
`A. Because those were the hospitals with which the referring paediatricians had established relations. The Inquiry will know that can be for a variety of reasons. As a consequence, there was an established pattern of referral. At that time, the pattern of referral, once established and once regarded as satisfactory, is likely to be retained. Indeed, the patterns of referrals to England throughout the period with which the Inquiry is concerned, indeed, up to the present day, are agnostic of the establishment of a specialist service if the clinician concerned believes it is in the best interests of the child they be referred elsewhere. Even when the Cardiff unit was up and fully functioning as a comprehensive unit, children were still referred to centres in England. So it comes back to an issue of the clinical preference of the referring clinician.
`Q. The clinical preference, the way you describe it, your understanding would be very much influenced by habit and personal relationships?
`A. I think those are factors. I think in this case we are talking about London hospitals with significant reputations for providing specialist services of this kind, which at that stage were not available in a comparable specialist service in Wales. So the logic of that would be that clinicians, for the reasons you have described, but also for the reasons I have referred to, would be looking to England to provide the service.' [184]
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Footnotes
[155] WIT 0106 0006 - 0007 Mr Nix
[156] WIT 0106 0174 Mr Nix
[157] John Watson, General Manager, Central Unit, B&WDHA from 1986. Chief Executive, Avon FHSA, from March 1990 onwards
[158] WIT 0298 0012 - 0013 Mr Watson
[159] WIT 0298 0013 Mr Watson
[160] Formerly the District Medical Officer for B&WDHA from July 1984 to 1988, and subsequently a consultant in public health medicine for B&DHA from October 1991 onwards
[161] Manager of the Children's and Obstetric Sub Unit from February 1986
[162] UBHT 0062 0299; meeting on 6 May 1987
[163] UBHT 0092 0002 - 0003 ; letter from Dr Baker dated 8 May 1987
[164] WIT 0298 0016 Mr Watson
[165] UBHT 0278 0302; letter dated 8 September 1987
[166] That is on adult patients
[167] UBHT 0062 0354 - 0355 ; letter dated 2 November 1987
[168] Dr Reynolds, East Dyfed Health Authority (UBHT 0278 0287 - 0288 ), Dr Skone, South Glamorgan Health Authority
(UBHT 0278 0291 - 0292 ), Dr Harrett, Gwent Health Authority (UBHT 0278 0283 - 0284 ), Dr R Doyle, Pembrokeshire Health Authority (UBHT 0278 0285 - 0286 ), Dr Hughes, Mid Glamorgan Health Authority (UBHT 0278 0293 - 0294 ), and Dr Littlepage, West Glamorgan Health Authority (UBHT 0278 0289 - 0290 )
[169] UBHT 0165 0019; letter dated 22 December 1987
[170] UBHT 0165 0020; letter dated 18 December 1987
[171] UBHT 0062 0384; letter dated 11 January 1988
[172] UBHT 0278 0268 - 0269 ; letter dated 23 December 1987
[173] UBHT 0278 0270 - 0271 ; letter dated 15 December 1987
[174] WIT 0298 0016 Mr Watson
[175] UBHT 0278 0174; letter dated 18 October 1988
[176] UBHT 0103 0045; letter dated 20 July 1989
[177] WIT 0058 0008 Mr Gregory
[178] T21 p.16-17 Professor Crompton
[179] UBHT 0194 0010; letter from Mr Williams dated 26 February 1991
[180] WIT 0058 0008 Mr Gregory
[182] WIT 0070 0002 Professor Crompton
[183] WIT 0070 0002 Professor Crompton