Annex A > Chapter 22 - Concerns 1987 > Concerns > Concerns expressed by South Western Regional Health Authority (SWRHA)
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Concerns expressed by South Western Regional Health Authority (SWRHA)
28 Miss Catherine Hawkins, Regional General Manager for the SWRHA 1984-1992, told the Inquiry that she had concerns about the Bristol cardiac surgical service in the late 1980s. They were focused upon the adult cardiac service and largely, but not exclusively, on waiting times and throughput. [28] They were explored in the following exchange:
`Q. You tell us in your statement, words to the effect that for some time before 1989 you had heard or had some concern that cardiac surgery in Bristol was not up to scratch.
`A. It was a fact that at district reviews in the north and the south of the county, DGMs advised us not always formally in a meeting but sometimes at lunch afterwards that they had cardiologists who were not happy with the Bristol Unit. Part of that, they thought, might be historical because people had been used to sending patients to the Brompton and to Oxford, but partly they thought that there was a general dissatisfaction with outcomes, whether operations were done in time, whether the patients waited too long, but they could not be specific and their cardiologists would not come forward to make statements.
`Q. Can I put flesh on this? These were conversations that you had not just in the formal review but around it?
`Q. Because if one looked to the formal review, was the formal review minuted?
`A. If it was raised as an issue, if we were having a dialogue about cardiac surgery and a concern was expressed, then it may well have been minuted, but again, in those days, it was very difficult, unless you had evidence, to name or shame a doctor.
`Q. At least the general position, appreciating that cardiac surgery may be slightly unusual because of the cardiothoracic register, but the general position was that you would know that you had not got chapter and verse to go on because that was the defect in the information systems at the time?
`A. Yes. We had a hint that - we had hints, but we also had a situation where cardiologists who were dissatisfied were still referring.
`Q. So, when were the district reviews at which or around which these concerns were expressed?
`A. That varied in time. It is very hard for me to remember. I know that they were raised in - I know for sure they were raised in 1990 from one particular district.
`A. Yes. Before that, I believe it was about 1987.
`Q. Do you remember from where?
`A. I have a feeling that that is Cheltenham, but the DGM has died since, I am afraid, but I think it was Cheltenham.
`Q. Who else would have been present at the meeting that might remember?
`A. My Finance Officer was always there. The other officers varied, depending on what was being discussed. Exeter, definitely the finance man was there. He was present at all reviews.
`Q. So going back to what you can recollect about Cheltenham, probably 1987, thereabouts, you are not quite sure, do you recall the way it was put to you?
`A. That was not in a formal context; that was over lunch where Mr Hammond [29] said, "You know, we are not really happy with referring to the BRI; we would rather go to Oxford". Asked why, again we had this, "Well, we are not absolutely sure but they are not too happy with the performance of the Unit". We did ask them to be more specific.
`Q. Specific as to the performance?
`A. As to what the real anxieties were about because unless you had that sort of evidence, you could not go back and challenge the DGM and his consultants, who were not part of the regional staff unless you had something very specific to hang on to. You could convey the concerns, but you could not say what those concerns actually were.
`Q. The cardiologist who would have inspired the DGM's expression of concerns to you would probably be an adult cardiologist, would he?
`Q. So are we to take from that that probably these concerns related to adult rather than children's services?
`A. I have never had an official or informal hint about paediatric service.
`Q. Neither formal nor informal?
`A. No. Not to me personally.' [30]
29 Miss Hawkins was asked in the following exchange about the television programme `Newsnight' broadcast in 1998:
`Q. Can I read it out to you as what was said: "`Newsnight' can reveal that it was some ten years earlier when serious misgivings about Bristol's record for adult heart surgery were voiced by the woman in charge of the health service in the west to the Department of Health. Catherine Hawkins was Chief Executive of the Regional Health Authority from 1984 to 1992. She declined to be interviewed on camera, but has told `Newsnight' of her considerable concerns about the role played by the Department of Health. A letter to `Newsnight' says that in the late 1980s there was pressure from both District Health Authority and Whitehall to expand the cardiac service, despite warnings that all was not well:
`"At many of our District Health Authority reviews, we find a reluctance to encourage referral by the cardiologists to the BRI because of, and I quote, unsatisfactory outcomes, close quotes. These views caused me sufficient disquiet to actively resist the rapid expansion of the service."
`She also told "Newsnight" that in 1988 her own Medical Officer warned her of a high death rate for adult heart surgery. Miss Hawkins says she raised this matter with officials from the Department of Health "on several occasions", and again there is a quotation:
`"Civil servants were hell bent on the numbers game. They were not bothered about the outcome of the operations; they just wanted to be able to quote a big increase in the number of operations being undertaken."
`First of all, are those quotations accurate in the sense that they come from a letter or from what you said to "Newsnight"?
`Q. The first of those quotations: "At many of our District Health Authority reviews, we find a reluctance to encourage referral by their cardiologists to the BRI because of, and I quote, unsatisfactory outcomes, close quotes."
`Did you say that to "Newsnight", either in writing or orally?
`A. Yes, because that, in the 1980s, was the feedback we were getting.
`Q. You say: "At many of the District Health Authority reviews".
`A. Yes. Well, two or three I consider many.
`Q. Because so far you have told us of Exeter in 1990 and Cheltenham in 1987. Was there any other you can recall?
`A. When we first started raising the issue of the fact that we would have to develop the BRI, we did have feedback then that they did not want to refer; they wanted to continue with Oxford and Brompton. That was not Avon, because Avon had always referred to the BRI, but the other districts did not want to go along that line.
`Q. You asked for the reason for that?
`A. Yes, and as I say, part of that could have been the fact that they were used to the pattern of referral and they told us patients were happy with that but we still had them saying, off the record, the cardiologists, that their doctors, in quotes, were not happy with referring to the BRI.
`Q. The words ascribed to you by "Newsnight" were, and I quote, "unsatisfactory outcomes ...". In other words, those words, "unsatisfactory outcomes", were being used to you in the course of one or more of these discussions, were they?
`Q. So DGMs were telling you that their cardiologists were unhappy about unsatisfactory outcomes?
`A. They may not have said "cardiologists" specifically, but they referred to their "doctors".
`Q. So you had expressed to you reluctance to allow the expansion of the BRI, cardiac surgery generally, adult cardiac surgery. Did you ask your RMO [Regional Medical Officer] to investigate?
`A. In that scenario, again, without very specific evidence or what he would be investigating, that was extremely difficult to do. In a situation where we would have to ask the individual doctors concerned for their specific cases, could we look at all their records, also, we did not have the manpower for that at that specific time, so I referred the matter back to the DGM, who should have done that.
`Q. So you could, could you, have asked your RMO, or indeed, even yourself asked the Unit at Bristol to provide comparative statistics such as they had of their performance as contrasted with national performance?
`A. To my knowledge, you could not have done that because units were reluctant to give up their figures. I spoke to the RMO before about that, and he said, well, you would never get a comparison because they do not want to give their statistics.
`Q. So although you as Region were responsible for the performance of the Unit, and although your Chairmen could talk and achieve results with the Chairmen of the Unit, you would not have been able to find statistics of outcomes even if they had them?
`A. We were not responsible for the performance of the Unit; we were responsible for monitoring it, but the BRI was responsible for the performance of the Unit.
`Q. Let us stick with monitoring. Monitoring involves getting figures and seeing how they compare against some standard?
`A. I think in hindsight that is easy to say. If you were there at the time, in the 1980s, that was not easy to do.
`Q. Did you or your RMO try to get the figures from the BRI?
`A. I would have to say no, because I would not have had the evidence to go in and demand such figures. A reluctance on the part of districts who were very content to refer out of region and not to the BRI, without being able to identify what they meant - what did they mean by unsatisfactory outcomes - was not a reason to put in two or three people to try and identify and collate statistics by hand, which is what it would be. There was no computerised record at that time.' [31]
30 Miss Hawkins told the Inquiry in the following exchanges about relating her concerns to Dr Roylance and others:
`Q. Do you recall yourself, or do you understand that your RMO ever spoke to Dr Roylance about these concerns?
`A. If I recall, there is somewhere on 1980s, in quotes, reviews, an item on that subject with the Bristol authority. I have spoken to him informally about problems there.
`Q. Do you recollect when it was that you spoke to him informally, roughly?
`A. Roughly? It must have been, I think, round about 1987.
`A. It would have been more than once because I would have had some feedback on it. If I had said to him, "Have you got a problem", I would have expected him to come back and tell me what the problem might be.
`Q. Do you recall as best you can how you raised it with him, what sort of thing you said?
`A. I would have told him that we had had bad feedback from other districts and that it looked as though there might be a problem, did he think there was and if he did, could he go and investigate.
`Q. Do you recollect the feedback that you got?
`A. Yes. He told me that they had identified an individual that they thought might be the problem, and that they were going to change that situation in the Unit and another consultant was being appointed and things should get better.
`Q. You can answer the next question "Yes" or "No". Did he identify the individual, the particular doctor who was thought to be the problem by name?
`Q. Was he a surgeon in cardiac surgery?
`Q. So far as you are aware, did he retire shortly afterwards?
`Q. After that, do you recall any further expression of concern by DGMs of districts other than Bristol & Weston?
`A. I really cannot recall that -
`Q. Until the time you came to Exeter?
`A. It seemed to go quiescent until round about late 1990. I believe in 1990 we held reviews in December.
`Q. I know you have been answering from memory, but if we go back to page 2 of your statement and go to the foot of it, the third paragraph in paragraph 11, you have identified the additional consultant who was to make a difference and that was, as it turned out, to be Mr Dhasmana.
`Q. We know he was appointed in 1986, so the time that you were looking at must have been a little bit earlier than 1987?
`Q. Can you help with whether you ever raised with the DGMs elsewhere whether things now seemed to be better or all right or words to that effect?
`A. It sounds - I mean, that would have been done on an informal network, because I did have AGMs who were responsible for individual districts, and that would have been done when they actually sat with them to see what should be coming up as agenda items at our reviews. I mean, cardiac surgery was a very small part, as I have tried to explain, of the total acute and other services in the Region, so it was not high on my agenda every single time I sat down with a DGM.
`Q. If one scrolled up to paragraph 7 on the same page, maybe you have just given the reason why you put it this way, you desire: "The main catchment area for the BRI ... Local cardiologists did not state dissatisfaction ...". It is a double negative. Did you put it that way because they were saying they were dissatisfied?
`A. No, there was never any issue from the cardiologists from the BRI or around Somerset that there was a problem with the Unit. [32]
`Q. Can we go back from that discrete topic to the question of the concerns that you heard being expressed and the way in which you approached them? "Newsnight" record you as saying ...
`"At many of our District Health Authority reviews we find reluctance to encourage referral by their cardiologists to the BRI because of, and I quote, unsatisfactory outcomes. These views caused me sufficient disquiet to actively resist the rapid expansion of the service."
`That last sentence: "These views caused me sufficient disquiet to actively resist the rapid expansion of the service." Is that a faithful reproduction of what you told "Newsnight"?
`A. Yes. It is what I told the Department. I resisted them on one or two years.
`Q. So it is true that is what you did, is it?
`Q. How did you actively resist the rapid expansion of the service?
`A. We would not put the capital investment in.
`Q. So Region had funds which it could have allocated to the development of cardiac services but chose not to do so?
`A. No. The point was that we could make it a top priority and let something else go for that year, but while we were actually investigating whether it was the best place to expand, then we spent capital monies on developing other DGHs [District General Hospitals]. [33]
`Q. [continuing the quote from "Newsnight"] "Some DGMs gave vague indications that cardiologists felt BRI outcomes could be better but could not be specific in their concerns." There are about five vague words in that sentence. Can you help us to put more detail on that?
`A. If I recall, some of the issues were that because throughput was not very good, then if they referred, patients may wait too long and therefore they would be happier to send them somewhere elsewhere they knew they would be seen in a shorter space of time. Some felt that they could actually do all the tests that were required but if they sent them to the BRI, very often tests were redone and they did not seem to have a working protocol between them, which meant that maybe the selection of cases was not being adequately addressed. Those sorts of issues.' [34]
31 Counsel to the Inquiry asked Dr Roylance about Miss Hawkins' evidence in the following exchange:
`Q. What Catherine Hawkins has told us is that at some stage, and she thinks around 1987 ... she spoke to you and asked you to investigate some concerns including concerns in respect of outcomes. ... She says that she had regular reviews and she says she would have been asking for the District General Manager to investigate why there were problems in cardiac surgery, she was firm in attributing anything that she had to say about concerns to cardiac surgery as opposed to -
`Q. She said cardiac surgery and she did tie it to adults.
`A. Can I tie it to adults to simplify the conversation?
`A. Because what she was talking about at that time, and I remember the issue, was adult cardiac surgery.
`Q. In 1987 there was a conversation that you recollect between yourself - thereabouts - and Miss Hawkins?
`Q. Her recollection was that you told her that the authority had identified an individual they thought might be the problem and they were going to change the situation in the Unit, another consultant was being appointed and things might get better; that is her recollection.
`A. Well, her recollection is at fault. I must say that must be a figment of her imagination because I cannot relate any event to that comment. No cardiac surgeon retired early; there was no identification of any individual and I have to say that a circumstance of that nature is not something that would have slipped my mind subsequently. I cannot explain in any way, except she was a very busy Regional General Manager with the responsibility across the whole region, I cannot explain where that concept came from but it did not come from Bristol.
`Q. She linked it to the appointment of Mr Dhasmana.
`A. Yes, that was a new appointment that replaced nobody; that was an expansion of the service.
`Q. The other thing she told us about this period is that the Region were active in resisting moves to expand the service, the cardiac service in Bristol in general because of their concerns about the nature of the service provided; can you help on that?
`A. I did not know at the time and it does make a number of previously inexplicable things perhaps understandable. It was known, recognised nationally as well as locally, that the South West was grossly underfunded for cardiological and cardiac services for adults and we were constantly pressing Region to fund more realistically the service pressure on the department. I was aware that there were considerations of creating a second centre at Plymouth, there is no secret about that. But at that time the traditional referral pattern for the south of the region was east to London and not north to Bristol. I do not know about the actual distances but the journeys were of a similar problem, similar time. So there was south of the region referred to London and the north of the region referred to Bristol but the cardiac department, particularly James Wisheart who led it, were constantly in negotiation with Region to expand the service to be more comparable with the demand. I could never understand why that funding did not materialise because the need was quite clear and opening a unit at the south of the region was not going to address that issue because it would absorb, presumably referrals which were currently going to London and actually not being funded by the South West Region, and I did not find that understandable at the time and I think it is more understandable now.' [35]
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Footnotes
[28] It will be recalled that the service at the BRI was for adult and paediatric patients. The impact of one on the other is a recurring issue
[29] Mr James Hammond, District General Manager, Cheltenham & District Health Authority