Annex A > Chapter 12 - Waiting Lists > Waiting lists at Bristol > Attempts to reduce the waiting list
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Attempts to reduce the waiting list
28 There was clearly pressure within each Directorate within the BRI [32] to reduce waiting lists, especially towards the end of each financial year, particularly after the introduction of trust status.
29 Mr Wisheart described the attempts made to reduce the waiting lists in general as `a constant battle'. [33] He said:
`When we were doing 100 [operations] a year it [the waiting list] was too long. When we were doing 1, 000 a year, it was still too long. So although we were running faster and faster, we never actually caught up.' [34]
30 Mr Wisheart was asked what efforts were made to improve the waiting list situation at the BRI and the BRHSC. He told the Inquiry:
`In the Children's Hospital, first, a number of things happened. ... perhaps the more important thing was that the number of closed-heart operations that we did peaked around this time and subsequently became less, and there were two reasons for this - at least two reasons. The first one was that the cardiologists developed the ability to carry out certain interventions as a non-surgical procedure, in other words, as part of the cardiac catheterisation, so that some procedures that we had done at surgical operations were carried out at the time of catheterisation, so that reduced the number of operations. The second thing is that the trend towards earlier total correction of intracardiac abnormalities meant that we did less palliative work in young children to tide them over. So for those two reasons amongst others, the actual number of closed procedures declined following this time.
`So that is what happened at the Children's Hospital.
`In the Infirmary, the total capacity of the Infirmary did continue to increase, as I think you have pointed out, but I would have to say that the increase in throughput was predominantly in the adult area at that time. We had, by 1989 or 1990, achieved this level of 150 operations per year. It is not my recollection that there was a significant increase beyond that.' [35]
31 Miss Deborah Evans [36] indicated that over the period 1991 to 1995 waiting times were the biggest single issue in contract negotiations between the B&DHA and the UBHT. She also indicated however, that:
`This was a much bigger issue for adult services than it was for children's services across the District as a whole. In children's cardiology and cardiac surgery services (excluding those services covered by the supra regional contract for which Bristol and District Health Authority did not have a responsibility) [37] waiting times were rarely if ever an issue.' [38]
32 At the Cardiac Surgery Board meeting held on 23 November 1993, [39] it was noted:
`10.1 Waiting list initiative [40]
`James Wisheart asked if anyone wanted to discuss this.
`Janet Maher reported that planning was in progress and we were negotiating with Bath and Somerset.' [41]
33 Dr Christopher Monk, consultant anaesthetist and Clinical Director of Anaesthesia at the UBHT from January 1993, [42] wrote a letter to Mr Wisheart as Clinical Director dated 22 January 1993 on behalf of the Directorate of Anaesthesia, complaining about the introduction of waiting list initiatives at the end of the financial year. Dr Monk described how various waiting list initiatives were undertaken during the year, allowing sufficient notice for resources to be allocated to implement the initiatives, but at the end of the financial year:
`As in the previous two years, the end of the current financial year results in a number of requests by the Purchaser for new waiting list initiatives. The aim of these being to decrease the number of patients with prolonged waiting times. Unfortunately, these requests are made at short notice, to multiple Surgical Directorates and for a large number of cases of varying surgical complexity. ...
`... considerable moral pressure is placed upon all clinical staff to avoid the failure of care for these patients ... Yet by the simple expedient of planning more routine care for the Bristol and Weston patients then these waiting list initiative patients could have been treated as routine cases, with the highest standards of care during normal working hours.
`Should we, despite all our efforts, fail to respond to these initiatives, I do not feel it would be a failure of the Anaesthetic Directorate or the Surgical Directorate but that of a Purchasing policy which relies on last minute waiting list initiatives to provide medical care for the patients.' [43]
34 On 26 March 1993 Mr Jooman produced a report detailing waiting list statistics from September 1989 to March 1993. The graph in relation to paediatric cardiac surgery showed an overall trend of increase from 1989 to September 1991 and a dramatic reduction from September 1991 to March 1993. [44]
35 The first of these graphs shows the total numbers waiting, and the second shows the numbers waiting for more than one year.
36 In December 1993 Miss Lesley Salmon, Associate General Manager for Cardiac Services, and Mr Dhasmana wrote a memorandum addressed to `all cardiac surgery staff' regarding a waiting list initiative. It stated:
`We recognise and sympathise with the pressure this places on everyone and are grateful for the co-operation and willingness people have shown under the circumstances. No one is in much doubt, after three years of contracting, how important it is for us to meet the demand in the South West and to attract the work to UBHT. There will be further investment in cardiac surgery next year and we want purchasers to invest here! The intention is to avoid further waiting list initiatives if possible, and the key to this is to get our waiting times down overall. The Trust is actively planning to expand the service for this purpose in the coming year.' [45]
37 The Cardiac Surgery Management Board meeting on 29 March 1994 recorded that:
`Mr Dhasmana thanked everyone involved with the waiting list initiative for their help. A total of 39 patients had been treated on the scheme which was a great achievement.' [46]
38 Many of the clinicians involved in the paediatric cardiac surgical service felt that it lacked resources, such as theatre time and space and beds, in comparison to the adult service.
39 Dr Bolsin, consultant anaesthetist, said that: `The major throughput of cardiac surgical cases on the BRI site was related to adult cardiac surgery. In 1988 3 paediatric cardiac surgical cases each week would be undertaken compared to twelve adult cases.' [47]
40 Dr Martin's evidence to the Inquiry included this exchange:
`Q. ... it was certainly your perception from what you have been telling us that the fact of doing the two together, adults and children, sometimes meant children were delayed for longer ... than they would have [been] delayed had it been one service for children at one place?
`A. That might have been a factor. Equally it might just have been the actual allocation of paediatric beds within the adult department was inadequate for the throughput. By increasing the numbers on transferring, I think with the transfer from the Royal Infirmary to the Children's Hospital you would have gone up from essentially what were three beds being utilised to five or six and that would immediately have an impact on waiting.
`Q. You told the GMC, did you not, that the need for children having to compete with the adult list for paediatric time in the theatre made the delays ensue, or at least that was your general impression?
`A. As I have said, it is difficult for me to judge exactly whether it was pressure on theatre, pressure on beds on the intensive care unit, but I was aware that certainly some patients were waiting at the Children's Hospital longer than I would have hoped for.' [48]
41 Mr Dhasmana also took the view that running the paediatric and adult cardiac surgical services in the same unit led to conflicting demands. His evidence included the following:
`Q. So the pressure on beds from adults and the pressure on operating theatres from adults had, did it, an effect upon the waiting list for children?
`Q. And that meant that children were waiting longer for operations than they would have been if the unit had been solely a paediatric unit?
`A. We now know that is the case.' [49]
42 The Chairman of the Inquiry sought to confirm this in the following exchange with Mr Wisheart:
`Q. (The Chairman) ... during all of the time that you were seeking to bring about the various developments, not least the appointment of another surgeon and the movement to another place, you were, were you not, chasing almost mutually incompatible goals, namely, making sure you had enough children treated through and looking at them, whilst at the same time meeting increasing adult waiting lists, always with the same, not only people, but physical resources, numbers of theatres. I imagine that is not atypical in the Health Service ...
`A. I think you are correct to say it is not atypical. I think it was very typical. I am not sure that I ever had any other experience as a junior doctor or senior doctor in the Health Service.' [50]
43 However, the Inquiry heard evidence that when it was necessary to cancel operations, it tended to be the adult rather than the paediatric cases that were further delayed.
44 Kay Armstrong, Cardiac Theatre Sister, gave evidence that: `When it was necessary to cancel elective surgery to fit in urgent cases it was adult, not paediatric cases which were cancelled on these occasions.' [51]
45 Sister Julia Thomas, Clinical Nurse Manager, Cardiac Unit, said:
`There were occasions when the intensive care beds were occupied by seriously ill patients and other cases had to be cancelled. The adult cardiac cases were sometimes cancelled because beds were occupied by paediatric cardiac surgery cases, who sometimes tended to progress rather slowly and tended to take priority.' [52]
46 Alison Riddiford, Surgical Service Manager (General), told the Inquiry:
`If there was an emergency operation, then it might be that an elective procedure was cancelled, although this would probably be an adult elective procedure.' [53]
47 However, Mr Dhasmana recalled having to perform some of his surgery at night. His evidence to the Inquiry included this exchange:
`Q. So what restrained the unit from doing the operation was first of all waiting lists; secondly staffing, if I can say shortages ...; and thirdly, do I get the sense that if you operate on more neonates, there is less room for non-neonates, given the pressures on bed space and operating theatres caused by the adults?
`A. Well, it is an emergency operation. You cannot wait for the next period to operate, so you have to - I mean, if you look in my record of closed cardiac surgery, it was working at night and various things, so almost I was doing open-heart surgery every night and then other surgery next day. So this was adding something new which I do not think we were geared up to, really.' [54]
The impact of financial incentives/penalties on waiting lists
48 At a meeting of the Cardiac Surgery Management Board on 18 July 1994, Miss Salmon reported that:
`Somerset were applying a financial penalty of 20% of the procedure price for any cardiac surgery patient who waited over six months for treatment. Professors Vann Jones and Angelini expressed their concern about this clause given the difficulties with managing a number of purchasing pressures.' [55]
49 Although the concern related to adult and child patients, it provides a context in which to understand the management, in terms of waiting times, for paediatric cases.
50 On 21 July 1994 Ms Linda Williamson, Contracts Manager for the B&DHA, wrote to Miss Salmon, complaining that part of a waiting list initiative had not been implemented:
`As you can see in the enclosed documentation, UBHT agreed to perform 20 cardiac operations between 1 April 1994 and 30 June 1994. Clearly these have not been done and in fact the specialty is under performing against contract.
`One option would be for us to claw back the £127, 000.00.' [56]
51 At a meeting of the Cardiac Services Management Board on 26 September 1994, Miss Salmon:
`... drew to the attention of the meeting that an offer of £127, 000 had been made by BDHA to ensure a maximum waiting time for all their patients of 10 months, by April 1995.
`The Board agreed that she should put together a proposal for BDHA's approval. The Avon GP Fundholding Group had also approached cardiac surgery about purchasing extra activity, but this would be discussed with individual practices.
`Waiting time management was becoming increasingly difficult and complex with different waiting times being agreed with some purchasers. Financial penalties were also beginning to be imposed; £3, 000 for any South and West patient waiting over 12 months and 20% of the procedure price for any Somerset patient waiting over 6 months.
`The South and West Region definition of a longer waiter would reduce to 10 months next April, adding to the pressure.' [57]
52 At the meeting of the Cardiac Services Management Board held on 28 November 1994, in relation to waiting list management it was reported that:
`The letter to BDHA detailing how the £127, 000 non recurring waiting list resources would be used (circulated with the agenda) was discussed.
`Cardiology are over performing on the BDHA contact.
`RCF [58] will identify the names of patients and find out whether these can be counted and funded as part of the waiting list initiative.
`The additional 15 CABGs [59] and 2 valves required cannot be performed until Surgery is achieving contract for BDHA. RCF will explore arrangements for these to be subcontracted to the Glen Hospital. [60] The Board agreed that if subcontracting was to be necessary on a regular basis, a standing arrangement for one or two cases each week would be preferable to performing several cases at the end of the financial year.
`It was noted that weekend work was particularly unpopular.
`It was noted also that the additional Friday morning operating session was proving unpopular and difficult to implement. The issues of anaesthetic cover/funding and pressure on Theatre staffing need to be discussed. RCF to review with Mr Dhasmana and Mr [sic] Monk.' [61]
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Footnotes
[32] The establishment of the Directorate system is dealt with in Chapter 8
[36] Director of Contract Management, B&DHA, 1991-1995
[37] For example, paediatric cardiac surgery until 1994
[38] WIT 0159 0023 Ms Evans
[39] UBHT 0084 0163; minutes of the Cardiac Surgery Board meeting held on 23 November 1993
[40] The Waiting List Initiative was launched in 1987 and was aimed at reducing the number of people waiting over two years for treatment
[41] UBHT 0084 0166 minutes of meeting held on 23 November 1993
[42] Presently the Associate Medical Director for Strategic Planning, UBHT
[43] UBHT 0247 0183 - 0184 ; letter dated 22 January 1993
[44] UBHT 0270 0187; report produced by Mr Jooman dated 26 March 1993
[45] UBHT 0179 0201; letter dated 3 December 1993
[46] UBHT 0132 0055; minutes of the Cardiac Surgery Management Board meeting on 29 March 1994
[47] WIT 0080 0002 Dr Bolsin
[51] WIT 0132 0034 Ms Armstrong
[52] WIT 0213 0031 Julia Thomas
[53] WIT 0262 0022 Ms Riddiford
[55] UBHT 0226 0085; minutes of the meeting of the Cardiac Surgery Management Board on 18 July 1994
[56] UBHT 0295 0615; letter dated 21 July 1994
[57] UBHT 0227 0026; minutes of the meeting of the Cardiac Services Management Board on 26 September 1994
[58] Mrs Ferris, General Manager, Directorate of Cardiac Services, UBHT
[59] Coronary artery by-pass grafts
[60] The Glen BUPA Hospital, Durdham Down, Bristol
[61] UBHT 0227 0023; minutes of the meeting of the Cardiac Services Management Board on 28 November 1994