Annex A > Chapter 21 - Concerns 1986 > Concerns
<< previous | next >>
Concerns
1 Professor Gareth Crompton, Chief Medical Officer for Wales from 1978 to 1989, stated in his written evidence to the Inquiry that there was:
`... an evident undercurrent of dissatisfaction with the Bristol Centre. This, at a time when paediatricians from Wales not working in the Cardiff Centre, e.g. Gwent and Carmarthen, were strong in their support of the care their patients were getting in Bristol.' [1]
2 Professor Andrew Henderson, at that time Professor of Cardiology, University of Wales College of Medicine, and some of his colleagues were openly critical of the quality of work at Bristol. At a meeting between the Welsh Office and South Glamorgan Health Authority (SGHA) on 20 October 1986, Professor Henderson distributed a letter that he had co-written with Mr Butchart [2] and Professor I A Hughes. [3] As regards Bristol, the letter stated:
`It has been suggested elsewhere that Bristol provide a supra-regional neonatal cardiac surgical service for Wales. The overriding objections to this have been stated. Moreover it is no secret that their surgical service is regarded as being at the bottom of the UK league for quality, and it is difficult to see how this problem could be resolved in the foreseeable future.' [4]
3 Professor George Sutherland, a cardiologist at Southampton General Hospital from 1983 to 1987, indicated that he was personally contacted by Professor Henderson:
`During 1986 I was personally contacted by Prof. A Henderson ... with regard to paediatric cardiology services in Wales ... Prof. Henderson expressed his concerns to me about referring children from Wales to Bristol in view of the poor surgical results in that department. He suggested that it would be appropriate that I offer a service to Cardiff similar to that Dr Keaton [sic] and I were offering to Plymouth.' [5]
4 Professor Crompton told the Inquiry that he did take steps to try to find out if there was substance to Professor Henderson's allegations that Bristol was at the bottom of the league for quality. He raised the matter with Professor Sir Donald Acheson, then the Chief Medical Officer (CMO) for England. Professor Crompton told the Inquiry:
`... I decided to mention to my colleague Professor Sir Donald Acheson, the Chief Medical Officer at the Department of Health, the opinion of Professor Henderson that Bristol were fortunate to have been designated a Supra Regional Centre in 1984 and that the team there had not progressed year on year as maybe the Supra Regional Advisory Group and/or others had expected. We met regularly as CMOs do in various fora to do with the National Health Service and it was in the margins of one of these that I spoke with him about the Bristol Unit. I had no evidence to present as at no time had Professor Henderson supplied me with any, even though I and my Welsh Office medical colleagues asked for any material he had to substantiate his viewpoint. Sir Donald properly asked me to see his Senior Principal Medical Officer with responsibility for the Supra Regional Services Programme, Dr Norman Halliday. That I proceeded to do the very same day. I saw Dr Halliday in his office, the only time I recall visiting with him, although I saw him often at meetings elsewhere in London where we represented our two departments. I raised with him the misgivings that Professor Henderson had raised with me about the Bristol Unit. We had a brief and un-minuted discussion. I received no confirmation that there were problems, other than about waiting lists, which the Department of Health were considering.' [6]
5 Professor Crompton said that he had told Dr Norman Halliday, Medical Secretary to the Supra Regional Services Advisory Group, of:
`... repeated comments from Professor Henderson about his view that the quality of the service in the Bristol centre was not improving year on year, as might have been expected. That was the essence of what I said. I had no evidence other than that, and that was, I think, a fair summary of what I had heard from Professor Henderson from time to time.' [7]
`I would have hoped that he [Dr Halliday] would have been in a position to have assured me that there was no basis to what Professor Henderson was saying to me, or that if there was a problem, that he had been able to share a confidence as to the extent of it, if he knew. But I do not recall any acknowledgement either way in that conversation about that.' [8]
7 When Professor Crompton was asked what action he would have expected Dr Halliday to have taken upon receipt of the information that he had given him, he replied:
`Well, from Dr Halliday's reaction, it did not seem to have been news, because he focused on the waiting list issues, not the quality and outcomes issues, and as far as I knew maybe similar things were being said in other parts of England about other centres, he might be privy to. I was not. I did not know what was known or not known to Dr Halliday, and he kept any confidences that he had.' [9]
8 When questioned further he stated:
`I would have expected from the beginning, when they established the supra-regional centres, that there would have been a system of data capture and analysis and publication from each of the centres, distributed freely to the Department of Health and to Regional Health Authorities who were sending patients there from Wales or wherever and that the Supra Regional Services Advisory Group would have been in full knowledge of all the facts relating to this important initiative. If that was not the case, then I am surprised.' [10]
9 Dr Halliday gave oral evidence on two occasions. On the first of these he was asked whether he was aware of the concerns that Professor Henderson had in 1986. Dr Halliday replied:
`It does not ring a bell, no. I mean, throughout all the discussions with the Welsh Office and everyone in that area, there were constant concerns about Bristol, but they were vague concerns and they appeared to be about the problems of referral. We also had a situation of, quite properly, clinicians in Cardiff wishing to establish their own unit and if they were building that empire there, that would threaten Bristol. So one reason for not referring to Bristol may well have been to strengthen their own case. They would constantly send them to London whilst they argued for a service within Cardiff. So one had to balance these arguments very carefully. But no-one raised any concerns about the clinical outcome in Bristol.' [11]
10 Asked about discussions with Professor Crompton about concerns over outcomes at Bristol, Dr Halliday replied:
`I had many discussions with Dr Crompton. As I said earlier, I met with the Welsh Office regularly and we regularly discussed Bristol, but I do not remember any discussion with any clinician or official where the performance of Bristol was questioned. "Performance" I am interpreting as meaning clinical outcome.' [12]
11 When Dr Halliday gave evidence for a second time he had had the opportunity to read the oral evidence of Professor Crompton.
12 Dr Halliday explained that he now did recollect the meeting at which Professor Crompton had expressed to him the concerns of Professor Henderson. He explained:
`... we did not have a formal meeting. Professor Crompton was not coming to me to say "I have a major concern here that I need you to address", because had he done so we would have arranged a formal meeting, we would have had agendas, we would have taken minutes, we would have considered future action. There was nothing like that at all.' [13]
13 Dr Halliday went on to explain that, as there was no evidence to support Professor Henderson's concerns, as relayed by Professor Crompton, he could not take the issue any further. He said:
`I am sorry, but you receive information, you do not necessarily take action, but you do not dismiss it; you retain the information and if something else comes along to complement what you have just been told you might well take action. In terms of what Professor Crompton had told me, I had no justification for taking action. What was I expected to do? I could not go to the Royal College and say "A Professor Henderson in Wales is alleging there is something wrong in Bristol". It would be irresponsible of me to ask the College to investigate on that basis. If, however, I was presented with some evidence, some data to suggest there was something wrong then, yes, I could do something.' [14]
14 In the autumn of 1986, the Bristol Unit was visited by health officials from the Welsh Office. Professor Crompton explained that the motivation behind this visit was to:
`... explore for ourselves whether there was any substantiation of Professor Henderson's critical comments about the Unit'. [15]
In her report of the meeting, Dr Jennifer Lloyd, Senior Medical Officer, Welsh Office, subsequently wrote:
`... We did however raise the question of outcome with Bristol staff. They put to us the accepted point that outcome is influenced greatly by case mix. They were quite open in quoting outcomes for some of the commoner procedures they undertake. They see a gradual improvement in these as expertise grows and specialist equipment becomes available. For most of the more commonly occurring conditions their figures compare well with other centres. They acknowledge however that surgeons in different centres develop special expertise in rarer conditions and that outcomes may therefore vary greatly for these between centres.' [16]
15 As regards Dr Lloyd's reference to case mix, Dr Hyam Joffe, consultant cardiologist, said in evidence that he could see no reason for Bristol's case mix to be any different from that of any other unit in the country, [17] with the exception of Down's syndrome cases, since he claimed that Bristol was more ready to operate on children with Down's syndrome than other centres, particularly in the mid-1980s to early 1990s. [18]
16 As to the phrase in Dr Lloyd's report, `gradual improvement ... as expertise grows', Mr Wisheart was asked whether it could be seen as an explanation for under-performance. Mr Wisheart replied:
`I think it could equally be a positive statement, that as experience, expertise in the volume of work undertaken grows, then it is likely that results will improve. I do not think it has to be seen as an explanation for something that may or may not be inadequate.' [19]
17 Mr Wisheart was then shown figures [20] that indicated that in 1986 the number of open-heart operations carried out on children under 1 at the BRI was very small (24) and in previous years had been even smaller: 14 in 1985, 11 in 1984 and four in 1983. Mr Wisheart went on to explain that when he had made the suggestion to Dr Lloyd that `They [the Bristol Unit] see a gradual improvement in these as expertise grows', it was more a reflection of an aspiration rather than a statement of fact. He said:
`I think the historic setting of what we were talking about is very important, because surgery in the under 1s was something that had been at a very low level through the 1970s and was beginning to grow, so, okay, some folks were a year or two ahead of other folks, and quite a number of folks were not doing very much, and in the early to mid-1980s, we were in that latter group, and hoping to develop the work as others were doing.' [21]
`... those who are behind are seeking to achieve the standards of those who are presently in front of them ... That, I think, was everyone's goal at that time.' [22]
19 Mr Wisheart was asked about the phrase `They put to us the accepted point that outcome is influenced greatly by case mix'. [23] In his evidence to the Inquiry Mr Wisheart made several points about case mix. First, he pointed out that a unit doing a small number of operations would probably be doing a proportionally smaller number of elective operations and probably a proportionally higher number of emergency cases and that outcome in emergency cases was nearly always worse, simply because of their unplanned emergency nature. The non-urgent and, therefore, often less serious nature of elective operations regularly led, he said, to a better outcome. Mr Wisheart then referred to some figures that he had prepared in 1988. [24] He explained that he had prepared the comparative table as a normal exercise and not as a response to any concern over rates of mortality at Bristol that had been raised with him. The table showed that in some operations - Pulmonary Stenosis, VSD + PS, and TGA in particular - Bristol had results that were better than the national average, which Mr Wisheart had calculated. In other operations the results were broadly comparable to this national average: Aortic Stenosis and TAPVD in particular. In other operations including PTA, TGA + VSD and AVSD, Bristol was below these national norms. [25] Mr Wisheart's evidence was that out of 74 open-heart operations on children under 1 in the period 1984 to 1987, 20 patients died, and that if the national mortality figures for the year 1984 to 1985 were extrapolated to the Bristol case mix in the period 1984 to 1987, then one would have expected to see 19.24 deaths. [26] Exchanges between Counsel to the Inquiry and Mr Wisheart on this point were as follows:
`Q. The overall conclusion then that you drew from this was that the difference in overall figures in Bristol compared to the UK was because Bristol was doing a higher number within the period 1984 to 1987 of those cases which carried the higher risk of mortality.
`Q. And if one allowed for that in the way that you have done here, the results were so close as to be almost indistinguishable?
`A. Yes. I am not sure that "allow" is the right word because it suggests a concession, and I do not think it is a concession; I think it is a statement of reality, if I may.' [27]
<< previous | next >> | back to top
Footnotes
[1] WIT 0070 0004 Professor Crompton
[2] Consultant cardiothoracic surgeon, University Hospital of Wales, College of Medicine
[3] Cardiologist and Chairman of the Division of Child Health, University of Wales College of Medicine
[4] WO 0001 0006; letter dated 20 October 1986 from Professor Henderson and others to South Glamorgan Health Authority
[5] REF 0001 0149; letter dated 21 January 2000 from Professor Sutherland to the Inquiry
[6] WIT 0070 0003 Professor Crompton
[7] T21 p.29 Professor Crompton
[8] T21 p.33 Professor Crompton
[9] T21 p.72 Professor Crompton
[10] T21 p.72 Professor Crompton
[15] WIT 0070 0004 Professor Crompton
[16] WO 0001 0260; Report on NICS for Wales, December 1986
[20] DOH 0004 0028; Table of surgery 1975-1991 produced by the UBH/T
[24] UBHT 0167 0032. (These figures are 1988 figures. Thus, they may have retrospective value. They were not available, nor were other such figures, at the time of the visit by the Welsh Office.)
[25] See Chapter 3 for an explanation of these clinical terms