Annex A > Chapter 18 - Medical and Clinical Audit > Audit at district and unit level > Monitoring and review of performance by the District
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Monitoring and review of performance by the District
246 Ms Evans said that the process within the DHA for dealing with issues relating to monitoring performance and quality `varied according to the nature of the issue'. [295]
247 In the interim period between the formation of the UBHT in April 1991, and the formation of the Bristol and District Health Authority in October 1991, Dr Baker, then the DMO of the B&WDHA, engaged in discussions with clinicians including local cardiologists and cardiac surgeons, concerning the assessment of trends and attempts to develop outcome measures for adult cardiac surgery. [296]
248 In June 1991 he wrote to members of B&WDHA's Department of Public Health Medicine seeking ideas for items on audit for discussion with clinicians for the
1992/93 contracts. He stated that he had in mind the investigation of treatments that were effective, were applied to a substantial number of patients, and involved considerable resources. The suggestions received in reply did not concern cardiac care. [297]
249 In December 1991 Dr Baker (by then Director of Public Health for the B&DHA) wrote to Dr Thomas, as Chairman of the MAC, expressing concern over the lack of progress in implementing medical audit. [298]
250 Each year, the B&DHA received feedback in respect of the performance of the provider trusts. Ms Evans stated that in relation to the UBHT the feedback [299] for the first year, 1991/92, drew attention to the fact that in order for the system to work, the Trust would need to take responsibility for setting its own quality assurance framework and for making sure it was reviewing its services against its own framework. [300]
251 The feedback had identified as a weakness that the UBHT did not appear to have an overall approach to quality, nor were there individuals with clear responsibility for it. Ms Evans commented:
`I think that in 1990/91/92, which this report is relating to, both the Trusts and ourselves as purchasers were feeling their way in this new world of different responsibilities for quality assurance ... The UBHT later established a committee which was chaired by one of their non-executives ... I think that one was aimed at looking at marketing issues and so on, but it was certainly a committee which sought out feedback about UBHT services. I was invited to that. I think latterly the Trust also developed a committee which was specifically about looking at quality. So it was an issue which I think they recognised and addressed over time, although, at this point, I think our comment was valid.' [301]
252 Ms Evans drew attention in her written statement [302] to instances in which problems identified in one set of monitoring returns had not subsequently been addressed or followed up. She told the Inquiry:
`I think we were very active in quality monitoring. I think probably that if one were to look at other district health authorities we were at least as active as others and probably more active than some. I think in my statement I was also trying to demonstrate that through the iterative process, we were identifying shortcomings and within the UBHT's directorates, they were trying to put them right. I think that is what one would expect to see in any cycle of quality monitoring, that you try and establish your standards and then check performance against them and if you feel they are not good enough, then you take corrective action and go back and re-audit them.' [303]
253 In 1992, meetings were arranged between the District and each trust within the District. The meeting with the UBHT took place on 11 November 1992. [304] Dr Morgan stated:
`At this meeting (A09796), the Chief Executive of the UBHT, John Roylance, explained that his Trust would not be keen on reporting on audit of process measures but would be happy to work on outcome measures with Bristol and District Health Authority. The Trust agreed to develop proposals for outcomes to be measured in a number of specialties and a list was provided in January 1993 (A09799). This list included adult cardiac surgery - "coronary artery bypass grafting, hospital mortality by pre-operative severity of disease".' [305]
254 A regional perspective of the extent to which the DHA monitored quality of outcome was provided by Ms Charlwood, referring to the period after 1992:
`... the District Health Authorities do not appear to have used the vocabulary of safety in regard to quality, but they did include outcomes for patients as part of their consideration of quality issues.
`From the outset B&WDHA appears from its records to have tried to concern itself with qualitative issues, as distinct from quantitative issues such as the number of operations performed.
`(i) the criteria for judging quality appear to have changed from time to time, often in response to changing priorities or emphases on the part of the Government (such as waiting lists and unit costs, or the introduction of the `Patient's Charter');
`(ii) the criteria chosen, and their indicators, were mostly of a general nature and on a large scale, so did not draw attention to concerns about surgical outcomes in a particular specialty at a particular hospital; and
`(iii) much of the information that might otherwise have informed decisions about quality did not differentiate paediatric from other cardiac surgery.' [306]
255 She identified a development of the role from mid-1993:
`From April 1993 onwards, Health Authorities were given a more explicit role in promoting clinical audit, and funding audit through allocations and from 1995 through the "service agreements". In 1993, B&DHA discussed a joint strategy for clinical audit with UBHT (and the other local Trusts), and negotiated agreement of a small number of areas for audit on the grounds of shared concerns. Paediatric cardiac activity was not identified by UBHT or the Health Authority as an area of shared concern. These agreements were monitored through review visits by Dr Morgan, the director of Public Health, and the Vice-Chairman of the Authority, Professor Gordon Stirrat, to the Trusts.' [307]
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Footnotes
[295] WIT 0159 0029 Ms Evans
[296] WIT 0038 0024 Ms Charlwood
[297] WIT 0074 0037 Dr Baker
[299] HAA 0043 0011; Finance and Contracting Committee report
[300] WIT 0159 0030 Ms Evans
[302] WIT 0159 0190 Ms Evans
[304] WIT 0307 0005 Dr Morgan
[305] WIT 0307 0005 Dr Morgan
[306] WIT 0038 0022 Ms Charlwood
[307] WIT 0038 0014 - 0015 Ms Charlwood