Annex A > Chapter 11 - Referrals > Introduction

Introduction

1 The aim of this chapter is to set out the extent to which referrals to Bristol from its catchment area followed the pattern that might have been expected, and to present the evidence as to the pattern of referrals from the Bristol cardiologists and surgeons to other centres. The position in South Wales will be considered separately, since distinct factors such as the role of the Welsh Office and the development of a specialist paediatric cardiac unit in Cardiff influenced and altered referral patterns.

2 During the period of the Inquiry's Terms of Reference, the BRI and the BRHSC provided a paediatric cardiac service to a large geographical area, encompassing much of the South West of England and South Wales. This area is referred to in this chapter as the Bristol `catchment area'.

3 Bristol had historically provided a service to the catchment area through peripheral or `outreach' cardiology clinics conducted by the Bristol-based cardiologists, and by accepting referrals to Bristol from the catchment area. These arrangements were, in part, formalised for the youngest patients by the designation of Bristol as a Supra Regional Centre (SRC) for Neonatal and Infant Cardiac Surgery (NICS) from 1984 until 31 March 1994. [1] The function and organisation of the outreach clinics are dealt with in Chapter 10 - Outreach Cardiology Clinics.

4 On the establishment of the Supra Regional Service (SRS), initially nine centres were designated to provide NICS: Bristol; Birmingham Children's Hospital; The Royal Liverpool Children's Hospital; Killingbeck Hospital, Leeds; The Freeman Hospital, Newcastle; Southampton General Hospital; Great Ormond Street Hospital for Sick Children (GOS), London; Brompton Hospital, London; and Guy's Hospital, London. From a geographical point of view, Bristol was the obvious referral destination for much of South Wales and the South West of England. However, referrals did not always follow this pattern.

5 The table below shows occupied bed days (OBDs) for NICS by region of referral based on 1992-1993 data [2] and illustrates that referrals to centres outside the geographical catchment area was not something peculiar to Bristol.

6 The Inquiry heard that, generally, referrals would be from a paediatrician within the catchment area to a Bristol cardiologist (Dr Hyam Joffe, Dr Stephen Jordan and latterly Dr Robin Martin and Dr Alison Hayes) for an opinion or investigation. The cardiologist would see the child either at the BRHSC or at an outreach clinic.

7 If the cardiologist considered surgery was likely to be required, then the child would be referred to a paediatric cardiac surgeon. Usually a child referred to a Bristol cardiologist who required surgery would be referred on by that cardiologist to one or other of the Bristol surgeons, Mr James Wisheart or Mr Janardan Dhasmana. However, on occasion the Bristol cardiologist, or the Bristol cardiologist in conjunction with the Bristol surgeon(s), would refer a child on to another centre for surgery. This is considered in more detail later in this chapter.

8 In setting out the evidence on the extent to which the referrals to and from Bristol followed, or diverged from, the expected pattern, this chapter will consider the factors that may have influenced the pattern. They include:

• referring consultants' personal relationships with cardiologists;
• historical factors (e.g. referring consultants following an established pattern of referral to Bristol or elsewhere);
• contractual constraints;
• waiting lists at Bristol and at other potential alternative centres;
• financial incentives to refer patients in the catchment area to centres other than Bristol;
• views held by referring consultants as to the standards of care at Bristol and other centres;
• special cases such as children with Down's syndrome, children being considered for heart or heart-lung transplant or (after October 1993 in particular) neonatal Switches; and
• requests by parents.

9 This chapter will set out the information that was available to referring clinicians and parents on which to base their decisions on referral. This will include an examination of the extent to which those making referrals had available to them information about the standards of care available at Bristol and the other centres.

10 This chapter will also set out the information that was provided to parents on the referral of their child, whether to Bristol or elsewhere; about why their child was being referred to a particular centre; and whether and in what circumstances referral to centres other than Bristol was offered to parents as an alternative or substitute for Bristol.

11 In July 1999 the Inquiry wrote to consultant paediatricians and cardiologists who had been based within the Bristol catchment area, in 19 NHS trusts, during the period of the Inquiry's Terms of Reference, seeking their comments on their own referral practices. Most of those who replied and were able to provide evidence falling within the Terms of Reference are, or were, consultant paediatricians in hospitals in the South West of England and in South Wales. [3] Their comments and those of parents were a valuable source of information.

12 The Inquiry initially contacted 29 NHS trusts, seeking the names of referring clinicians. As a result, the Inquiry wrote to 88 clinicians employed in 19 NHS trusts. Eighty-one clinicians replied. However, of those 81, nine fell outside the Inquiry's Terms of Reference, either because they were not in post in 1984-1995 or because they dealt only with adults. Thus, the total number of relevant replies was 72. [4]

13 The Inquiry commissioned a statistical analysis of Hospital Episode Statistics (HES) for Bristol for the years 1991-1995 from Dr Paul Aylin. [5]

14 Dr Aylin was asked to look at referral patterns to the UBHT from its catchment area, and to compare them to referral patterns to other centres from their respective catchment areas. The question of different patterns of referral depending on differing socio-economic status was also addressed. The main finding of this analysis, which focused on open-heart operations between 1991 and 1995, was that the ratio of the residents going out of the UBHT catchment area for surgery compared to those coming in from other areas, is high in Bristol. [6] As regards children aged under 1 year, there were none from England outside the catchment area that came to the UBHT to be operated on. [7] However, a third of children under 1 year within the Bristol catchment area were being treated in centres elsewhere in England. With regard to socio-economic status, there appeared to be a tendency for higher proportions of under-1-year-old children who were from affluent areas to be treated elsewhere for open-heart operations, but other centres in England also displayed this trend.

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Footnotes

[1] Detail of the designation and de-designation of Bristol is set out in Chapter 7

[2] The figures are taken from an annex to a letter sent by Sir Alan Langlands to regional general managers in November 1993 (EL(93)100). See DOH 0002 0249 and DOH 0002 0253

[3] The Inquiry wrote to 88 clinicians in Bath & West Community NHS Trust, Bro Morgannwg NHS Trust, East Gloucestershire NHS Trust, Gloucestershire Royal NHS Trust, Gwent Healthcare NHS Trust, North Glamorgan NHS Trust, Northern Devon Healthcare NHS Trust, Pembrokeshire & Derwen NHS Trust, Plymouth Hospitals NHS Trust, Pontypridd & Rhondda NHS Trust, Royal Cornwall Hospitals NHS Trust, Royal Devon & Exeter Healthcare NHS Trust, Royal United Hospital Bath NHS Trust, South Devon Healthcare NHS Trust, Swansea NHS Trust, Swindon & Marlborough NHS Trust, Taunton & Somerset NHS Trust, University Hospital of Wales Healthcare NHS Trust, and Weston Area NHS Health Trust

[4] Three clinicians commented but were barely within the Terms of Reference (one worked in Taunton for a month in 1995, one worked in Gloucester from March 1995 and one retired in May 1984)

[5] Analysis of Hospital Episode Statistics, Aylin et al., 1999. See Annex B

[6] Dr Aylin added a caveat that the findings be treated with caution because of the difficulties of defining catchment areas. See INQ 0013 0045

[7] Table 1, para 5 above shows a figure for referrals to Bristol from Wessex. It should be noted, however, that Dr Aylin's report focused on open procedures only. So too should his caveat about the difficulty in defining catchment areas. See INQ 0013 0045