Annex A > Chapter 26 - Concerns 1991 > Concerns > Concerns expressed by South Western Regional Health Authority (SWRHA)
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Concerns expressed by South Western Regional Health Authority (SWRHA)
53 Also in the autumn of 1991, the SWRHA carried out interim reviews of the District Health Authorities (DHAs) and Family Health Service Authorities (FHSAs). On 20 November 1991 Miss Catherine Hawkins, Regional General Manager, SWRHA, wrote to Dr Roylance:
`I have just finished the interim reviews of DHAs and FHSAs Region-wide and, at all but one review, we heard how poorly Bristol Trust is now performing on Cardiac Surgery contracting, and as a consequence, some are shifting their contracts this coming year, others plan to shift them in 1993.
`Without exception the Business Managers were identified as "problems" in the negotiation.
`As currently, we at Region are reviewing Cardiac Units and our needs, and the fact we have invested in Bristol to serve the region and not just Avon - I would more than welcome your comments and action if you feel you are not in sympathy with the current rate and quality of performance of the Cardiac Unit.
`I am sure Mr Wisheart would like to be made aware of the gross dissatisfaction Region-wide.
`As a poor reputation takes an age to redress, perhaps we can act now to prevent further deterioration and syphoning off to Oxford and London?
`Sorry to be the bearer of "bad news".' [63]
54 In her oral evidence Miss Hawkins explained the background to this letter:
`It is the comments that we have had when doing the district reviews in relation to the fact that we were moving into Trust status; contracting was a major issue; they were not happy with the handling of their contracts; they were not happy with the service being provided, they thought they would get better services elsewhere; they really felt that when they had moved into purchaser/provider separation, their purchasers would want to shift away from the Bristol Royal Infirmary.' [64]
55 Miss Hawkins said that prior to the letter being sent, she had spoken to Dr Roylance:
`... what we have to bear in mind is that just before I sent this letter, I had had a dialogue with Dr Roylance.' [65]
`... because it was at that meeting that I told him. I mean, I would not just send him a letter out of the blue. We did actually have a discussion about what I found. I said to him, I am going to write to you officially and I want you to take it to Mr Wisheart to draw his attention to the fact that this Unit is not performing satisfactorily on all fronts.' [66]
`What I was seeking to achieve was to raise the fact with Mr Wisheart that not only was contracting an issue, but that the general quality of performance of this Unit appeared to leave something to be desired, and were there explanations for that that he could actually quantify to Dr Roylance. Because if we had that, we could either go back and reassure purchasers, or the Unit themselves could have done that in their contracting scenarios. And of course, it is a fact that if your business manager is not doing the best for the Unit, then the Medical Director should be having a say in that. That is what Clinical Directors were for.' [67]
`It was written to support Dr Roylance in a difficult situation because he had been, to my knowledge, trying to sort the problems out within that Unit over a period of years and it appeared that it still was not quite right. So it was actually in support of the Chief Executive. [68]
`With the demise of one consultant, taking on another, looking for a Chair of Cardiac Surgery and trying to get investment, and with a paediatric pathologist on the cards, all those things he had been trying to achieve: very difficult in a teaching authority where money is short, but he was trying.' [69]
59 Miss Hawkins, when asked what she meant in her letter by the words `... more than welcome your comments and action if you feel you are not in sympathy with the current rate and quality of performance of the Cardiac Unit, ' [70] said:
`If in fact he [Dr Roylance] investigated and he was not satisfied with what he heard, I expected him to come back and say, "I believe that the current rate and quality of service is bad and it is for all these reasons ...", and then we would have picked it up in a different way.' [71]
60 The following exchange expanded on Miss Hawkins' view as to possible interpretations of the intention behind the letter:
`Q. If it was to be suggested that those who dealt with the letter and responded to it viewed this as a letter about contracting and not about the quality of outcome of surgery, how would that strike you?
`A. I would have said it was a clever sidestep.
`Q. From what you are saying, Dr Roylance was well aware of the motive behind the letter; indeed, you say you wrote it to him to help him to deal with the problem that he had.' [72]
`When I had a reply from Dr Roylance, I believed it was not addressing the real issue, although I cannot remember what the reply was.' [73]
62 Miss Hawkins gave her view as to what the `real issue' was:
`The real issue is that there seemed to be general dissatisfaction in a major part of the region which the Unit Medical Director appeared to be disregarding.' [74]
`As I have said to you, the point being that cardiac surgery was not high on everyone's agenda but questions were being asked; if we do not like certain units, can we move? Implicit in that is the fact that they would have been looking at services like cardiac services.' [75]
63 Dr Roylance replied to Miss Hawkins' letter on 3 January 1992:
`Thank you for your letter of 20th November. I am very grateful to you for conveying to me the opinions they expressed to you. Only Exeter District Health Authority has voiced such concerns directly to us. I have had the opportunity of discussing the matter in depth and would like to repeat what James Wisheart has said to me:
"The present unit was opened in September 1988 with the funding for 675 open heart operations per year. Each year since then the target number has been significantly exceeded. Seven hundred and twenty eight operations were performed in 1989 (the first full year of working) and 696 in 1990. In the first half of the present financial year (with continuation contracts from the previous years) in excess of 360 operations have been carried out. Further, for each purchaser in the South West the number of operations done at the half year point is within + 4 of the target number, with the exception of Bristol and District which was further over target at that date.
"It is clear that each purchaser is receiving the volume of work contracted, in many cases more than the contracted volume.
"The Cardiac Unit has carried out its work within the allocated/contracted sum of money in each of these years. Further, our prices compare favourably with eg. Oxford, Southampton, St George's and Leeds.
"3. Quality (medical). The outcome of our work is at a quality level similar to that expected nation-wide, as documented in the UK Cardiac Surgical Register.
"Quality of Care (organisation: e.g. waiting times).
"Waiting times for surgery is the least satisfactory part of the service we offer. The `waiting time' is the legacy of the old `waiting list', which for the Cardiac Surgical Unit reflected the fact that facilities in the South West (ie. in Bristol) have met about half the calculated need throughout the last decade, and this situation remains the same following the 1988 expansion; a conservative estimate would suggest that 1400-1500 operations are needed annually for citizens of the South West region, and this estimate is likely to be revised upward in the next year or so. The excess of demand over provision is illustrated by the fact that although immediately after the expansion the number waiting and the time of waiting fell for 6-9 months, by the second half of 1989 the number of referrals were rising rapidly, so that by 1990 the numbers waiting were greater than before the expansion. At present only a small percent wait over a year, but for our patients this is too long, the average time to operation is approximately 6 months.
"Contracting has highlighted this issue and I believe offers a solution. Whereas in the past we sought to offer a service to allcomers in the South West - hence the long waiting list, we now have a commitment defined by the contracts. Therefore, we are monitoring new patients coming onto the waiting list - so that for each purchaser these shall match the number contracted for, and being operated. Once that balance is established we shall be in a position to make a `one off' effort to reduce the waiting times, without simply `sucking in' more patients. This is what we have been planning and beginning to implement over the last two months."
`The situation is not helped by a similar problem of over referral to a Cardiology Department.
`My personal view is that we must all decide what to do about the potential of over referral to services. We must all attempt to increase the service funded by purchasers and agree protocols to reduce referrals to that level.
`In parenthesis I would point out that waiting times perceived by purchasers probably include wait for cardiac catheter plus wait for operations.
`I am satisfied that the true quality of the service is, under the current stress, of a very high order. The immediate improvement in areas of waiting times could only be achieved by a more overt selection of cases to be accepted for treatment. This would precipitate a similarly overt rejection of those excess of the funded workload. I fear this would be currently politically unacceptable.
`I would be only too pleased to discuss this directly with you if you have any time to see me.' [76]
64 Miss Hawkins indicated in her evidence that, in her opinion, Dr Roylance's reply did not deal with the `real issue'. She explained:
`Because it was statements actually saying that everything was all right when in fact what was being conveyed back was that it was not, and therefore we were at a dichotomy between two opinions. That did not sit easily with me because it did not seem to address what the final outcome of treatment was all about. It is all right to have a throughput, but I was not absolutely confident that we were getting the best results, particularly if people were waiting a long time to go in for operations.' [77]
65 The following exchange further explored Miss Hawkins' view in the light of Dr Roylance's response:
`Q. If the outcome, at the top of the page, was "at a quality level similar to that expected nation-wide"; if, in other words, you could look at the UK Cardiac Surgical Register and compare the results at Bristol with that, then your doubts about the length of time that children or others, adults, may have waited for an operation would be resolved, would they not?
`A. If a cardiologist tells you that he is not happy, even if it is through a third party, that he is not happy with the outcomes, then there is something wrong in that service because he appears to be happy with other units.
`Q. But other units he has not sent his cases to?
`A. That he used to send his patients to.
`Q. Why should the customer always be right?
`A. I do not think in that sense I would perceive the cardiologist as the customer. I think he was the agent acting for the customer.
`Q. What he may seem to be saying is that, because these concerns had been expressed, they had to be right; no smoke without fire?
`A. No, I think they had to be thoroughly investigated, and I was not at ease with this, that it had been properly investigated.' [78]
`I actually did not feel confident in this and I wanted to speak to Mr Wisheart myself to see what he had to say. So I did go to the unit myself ... shortly after receipt of the letter.' [79]
67 In the following exchange, Miss Hawkins said that she spoke to Mr Wisheart `within the week' of receiving Dr Roylance's letter and went on to describe the content of their discussions: [80]
`Q. You spoke to Mr Wisheart. Do you recall when exactly this was, because the letter from the BRI to you was dated 3rd January 1992?
`A. No. I know it was one afternoon. I have not got my old diaries, I am afraid.
`Q. Roughly how long after getting the letter?
`A. It would have been within the week, I think.
`A. Mr Wisheart showed me around the Unit and I spoke to nurses and technicians and a few of the patients. Then, when we finished, I said to him that I was concerned by the fact that cardiologists, through their DGMs [District General Managers], were actually raising concerns about outcomes. We did discuss - he did tell me that some of the cases that they had were very difficult. Some were being referred too late and that age-related situations could affect good outcomes. I did say to him that he needed to be more discerning in the type of cases that he attempted; that obviously he needed to be competent, and confident, that the cases he was treating would produce the best outcomes; that he was having problems with referral, he needed to speak to cardiologists to make sure that referral rates and timings were much more appropriate to the type of treatment to be given.
`Q. Did he say anything about the overall figures and how they compared with elsewhere?
`A. He thought that they were performing satisfactorily, and I said that with the best will in the world, you may think that within a Unit like this, where you might all be reinforcing your own opinions, but if external agents who are going to contract with you perceive that you are not doing well, a reputation lost is very hard to get back and therefore you need to get on board with your purchasers to ensure that you deliver the service that they require.
`Q. So he essentially was denying the problem, was he?
`A. I think he was saying that it was not a big problem.
`Q. You said a moment ago that he said that they were doing satisfactorily at Bristol. In your statement you say in the second sentence of the last big paragraph on page 4: "He admitted they [the outcomes] could be better ..." How do I reconcile those two statements?
`A. Because of the fact that he said at the time that they were having too-late referrals, age could make a difference, be it at the young end of the scale or the other end of the scale. If they got patients that were too old, for example, ... that could have a bad outcome and that could be affecting outcomes and that is when we entered the dialogue about, then, you need to be discerning about age relation, that you get them in time and that people are referred properly and that you change this perception that purchasers have.
`Q. Did he actually say anything about the outcomes being such that they should or could do better?
`A. I recall that he said, yes, they could be better if these things were changed.
`Q. So in other words, the results were satisfactory for the cases they were dealing with, as opposed to the results were not satisfactory and in any event, there were these problems?
`A. Yes, against the fact that he thought that they were having much more difficult cases than many units had and therefore the outcomes were reasonable, set against those sorts of criteria.
`Q. Was there anyone else with you on that visit?
`A. No, I went on my own because I felt that if we needed to speak within four walls, then we should have that opportunity.
`Q. ... Mr Wisheart, for his part, does not recall this visit, or any such visit, after the letter. Are you sure you are right about that?
`A. I know what I know happened.
`Q. If you look at the paragraph at the top: "... I recall advising him [Mr Wisheart] that if the BRI shortly achieved trust status and districts did not value the quality of the service the unit offered, they would shift their cases elsewhere." Is that what you recall telling him during the course of this conversation?
`A. No, that is a misquote, actually. It is the gist of what I did tell him that the districts, in contracting, would shift their contract and he would actually lose money for their service.
`Q. What about the words "if the BRI shortly achieved trust status"?
`A. No, that should actually read "the BRI having achieved trust status" that the purchasers would now be able to shift whereas before they could not, because the Region actually controlled the contract.
`Q. I appreciate things were done at a rush when you made your statement.
`Q. Did you check your statement over, though, before you signed it?
`A. I checked it quickly off the fax and phoned back with five amendments.
`Q. Because the BRI in fact achieved trust status in April 1991.
`Q. So if this conversation took place in 1992, it could not have taken place as described in your statement?
`A. I remember it happening because 1992 is the year I left and I was actually tying up ends before I was going to go.
`Q. And this is one of the ends, is it?
`A. Well, when you have purchasers who are going to be a major threat to a major unit within a teaching hospital, it is not something that I wanted to leave for somebody else.
`Q. You were inclined to accept the explanation that he was giving you?
`A. I am not a cardiac surgeon so I was not in a position to judge, but it sounded feasible that if you actually get late referrals and the age is a problem and the case is very difficult, then you would not have as good outcomes as if everything else was put in a correct order.
`Q. So not being a cardiac surgeon, did you take any further advice on it?
`A. I actually felt, from our talk, that he did intend to address those issues, particularly talking to the cardiologists in trying to sort the problem out.
`Q. So you thought it required no further action on your part?
`A. Having had the conversation with Dr Roylance and with Mr Wisheart, having had a reply from them, having put an audit person in there to begin to sort audit out, I really felt that we were on the road now to being able to evaluate, in fact, what the real outcomes were.' [81]
68 Dr Roylance was asked in some detail about the letter of 20 November 1991:
`Q. This letter involved, did it not, questions of quality performance?
`A. Yes, but I do not think it involved questions of clinical outcome.
`Q. What did you understand to be meant by "quality of performance"?
`A. At the time - this is the early days of the Trust, the relatively early days of the Trust, and we were making enormous efforts to measure everything in terms of service that could be measured in order to improve it. It is very difficult to define a term, but these were all the facets of healthcare excepting the outcome, the clinical outcome of the service: how long people waited on waiting lists, how long they waited in outpatients before they were seen by a doctor, how long they waited in the admissions area before they were taken into hospital, food and all the other things, all that mass of supporting service, the environment in which clinical care was given, which I think there was (quite properly) anxiety at the time that they had been sacrificed to the altar of clinical care from the altar of clinical outcome and there was an immense effort at that time. So when we used the term "quality" at that time we were talking about things which eventually got swept into the charter mark negotiations; that is what "quality" was.
`Q. That is the way you read it you say?
`A. No, you must not say that it is the way I read it; I discussed this with Catherine Hawkins, I knew precisely what the problem was and this was a letter which she wrote in order to be supportive of me in trying to resolve the situation. That was the way we worked; I used to see her once, twice a week about issues and we discussed this. I have explained to you that we had a problem when we created a Trust of the very substantial underfunding of adult cardiac surgery. That was then transferred from regional funding, which was at least a straightforward discussion with Region - it was not very productive for the reasons we have discussed - but now that money had been delegated to all the districts in the South West who had individually to agree contracts with us for cardiac surgery, and the money they got did not match the service they required and we had difficulty in transferring from the previous centrally funded service to this system of contracts with a whole series of local districts.
`Q. You asked Mr Wisheart to draft you a reply to this?
`Q. He produced three drafts. Shall we have a look at them? UBHT 38/432: if we go right down to the bottom of the page, it is the first draft "Quality". He has looked at the expression "Quality" used in Catherine Hawkins' letter. He divides it, as we will see, into "(a) Outcome (Medical)" and "(b)" - go to GMC 4/48 for the next page - "Quality of Care (Organisation: e.g. Waiting times)". Go back to UBHT 38/432, the foot of the page: "Outcome (medical). The outcome of our work is at a quality level similar to that expected nation-wide, as documented in the UK Cardiac Surgical Register." He is reading it as a question not only of quality of performance in the wider sense, but also in terms of quality of outcomes?
`A. Yes, I did not dispute that and at that time, and I believe still, the clinicians in the service believed that outcome (medical) as he said was infinitely more important than this new influx of non-clinical/non-medical care measures of quality.
`Q. He gave you three drafts and he gave you the right to choose between them?
`Q. You did not disabuse him you say of his view of quality but you did change or amend his drafts to make one of your own. We pick that up at UBHT 38/426.
`A. Yes, on this situation I picked out the relevant part of his longer suggested letter and put it in inverted commas so there was no question that that was his view; that was one of the things that Catherine Hawkins was rather anxious I should ascertain and I topped and tailed that contribution.
`Q. If we have a look at UBHT 38/427 because this is your final editing of his drafts. You include in your reply what he says about "quality (medical)" so you were adopting it?
`A. No, I was transmitting information he wished me to give to the Regional General Manager. I do not see that as changing the basis of Catherine Hawkins and my original conversation and what we were addressing.
`Q. If your letter was not about quality in that sense at all, why respond to it in those terms?
`A. I was quoting James Wisheart's response and I do not think there was any reason to take that element out of it.
`Q. Your letter in response to hers contains, in part, a response which is off the point but which you included simply because Mr Wisheart drafted that for you?
`A. No, but I do not think Mr Wisheart would have thought it was off the point and I was not going to suggest to him that suddenly his wish to maintain high quality of outcome was irrelevant. I am sorry, but I saw no reason - and see no reason now - why I should have edited that statement. ...
`Q. Dr Roylance, a little while after this letter from Miss Hawkins, you got a letter from the South West Regional Health Authority from a Mr Wilson [Arthur Wilson, Regional Treasurer, SWRHA, 1984-1993]. Can we look at that? It is UBHT 38/411. The date in the top left-hand corner is misleading, 31st January 1991. I think I can say that for two reasons: it has your date stamp on it dated 7th February 1992, as you can see on the left-hand side and in the first paragraph of the text it talks about published professional advice in November 1991. So I think we can date this letter as 31st January 1992. I will show you in a moment your reply to it. That letter comes. If we scroll down: "With regard to the advice on the development of a second cardiac centre and additional catheterisation services, I am now working with those from the south of the region on proposals." He is writing to invite you to produce a proposal for cardiac services that takes into account (a) increased capacity; (b) unification of children's services; (c) steps to meet quality and cost concerns of purchasers. Pausing there, did you read this letter as talking about quality in the sense that you had understood Miss Hawkins' earlier letter to be talking about quality?
`A. I cannot be certain. I do know at that time the medical profession as a whole were restive about the quality measures as applying to everything but the business we were in, which was getting patients better. Therefore, I do not know to what extent the letter I had written had influenced the writer of this in writing this. I need to see the supporting papers he says he has sent, or I think he has sent. So I cannot tell whether Arthur Wilson had moved forward as we were trying to move everybody forward at that time.
`Q. Your reply to him is at UBHT 38/406. That enables you to see the reference at the top.
`Q. Can we go back and look at the reference and you can let us into the secret of what you get from that?
`A. "AM" is the typist, "JDW" is the source of the information, and "JR" means I signed it.
`Q. We go to the second page, 407, the first paragraph, about seven lines down: "However, we were confused and disappointed to see the repetition of the statement that `some district health authorities are dissatisfied with the service from Bristol on both cost and quality grounds ...' as we believe that this is both unfounded and potentially damaging to us. Surprisingly, in the next section of the same paragraph it is stated that `there are no waiting list pressures'; as I stated in my letter to the RGM, waiting time is the glaring problem." Is your letter to the RGM part of the same correspondence we have been looking at in response to Catherine Hawkins' letter to you in November 1991?
`A. Yes, I think this is the next stage of having written back to Catherine, that there is a consideration of whether they were going to increase the funding to adult cardiac surgery. This is the first step in that sort of negotiation. I think that there is a confusion here - at this distance I cannot tell you where on the spectrum it was - because I do know that in management circles quality had nothing to do with patient outcome. In consultant circles that was not happily accepted - not that the non-clinical quality measures were not important, but they were not the most important and we were doing our best to keep introducing into the conversation that the purpose of a contract was not waiting time in outpatients, but patients getting better.
`Q. We can go on in the paragraph beginning "Just one purchaser ...". Let us look at the full paragraph: "Just one purchaser (Exeter) has complained to us and that is specifically about waiting times. The Regional Committee in Cardiac Services had no issue to raise with UBHT other than waiting times. As a consequence, I am not quite sure what you have in mind for the comparative exercise in quality and therefore would need to discuss with you the whole issue before offering specific advice or suggestion. If medical outcomes are an issue, then authoritative advice would be needed which could be obtained by inviting the Royal College of Surgeons, the Society of Cardiothoracic Surgeons to nominate a suitable senior person; if an assessment by mid-March is needed it might be best for the RHA or the RHA with the UBHT ..." It goes on. At least a paragraph of your response, albeit drafted on information received from Mr Wisheart, appears to be about quality issues in the outcome sense?
`A. No, there is an "if" outcomes issue. This is trying to clarify a confusion. I think it confirms what I have just said to you, although I have not read this recently and that was, there was at that time a concept of quality within the Health Service within this new general management function which had been imported from Sainsburys, Marks & Spencers and elsewhere, that total quality management should be done, and the managers were instructed to measure all what I call the "non-clinical" elements of the service to ensure that patients were being properly treated, but they specifically excluded patient outcomes, what the people in service thought was the business we were in. There was a conflict at that time. When we have statements from Region to say they are unhappy about quality measures, there is an issue there, what quality measures are you talking about? And if medical outcomes are an issue - not "they are, it is accepted", but if they are an issue, then there is an indication there of the proper way of addressing such an issue, which is what I would say this shorthand was activating the proper professional approach to an issue of that nature.
`Q. The proper professional approach you identify in your letter is that if there is an issue, we will need to have an outside report on it.
`A. That is right. Because of the new concept of competition which was more fictional than real, it is suggested here that to take the nearest units, Oxford and Southampton, to come and make a comment on whether they think patients should go to Bristol or Southampton or Oxford was not a constructive way forward.
`Q. It is a bit like asking your competitors to say whether they are proper competition?
`A. I do not know how much they were competitors, but certainly there was an encouragement in those years that we should pretend we are all competing.
`Q. If one goes back to the letter which sparks this off, the letter of 31st January, UBHT 38/410 ... what led to the detailed discussion as to whether it might be necessary to have some sort of outside investigation was the suggestion by Mr Wilson that you might produce a proposal for cardiac services taking into account steps to meet quality and cost concerns of purchasers, whatever that meant.
`A. That was the issue: what did it mean?
`Q. If you go overleaf, because I think it may also have been this you were responding to, UBHT 38/412, the first paragraph: "In addition, in order to ensure that the best quality standards are identified and built in, I am asking for your support and co-operation in commissioning an agency to carry out a comparative appraisal [this I think is where the idea comes from] of these standards between yourselves and other centres." That is what gives rise to you saying, "Is it outcomes? If it is, this is the way to go about it"?
`A. Yes, and in fact there is the implication, which there always was at that time, that we would rather occupy our time on outcome measures of quality than the other elements of quality.
`Q. What you appear to be recognising in these two letters is that if there were a serious concern about the outcome measures resulting from cardiac surgery, that the appropriate step would be some form of appraisal or investigation by outside authorities who were truly independent and could give you another view?
`A. That is right. It is reminding Arthur Wilson, and through him the people concerned, that managerial issues were my concern, professional issues were the concern of the profession.
`Q. Does it follow that if any such concern had been expressed about a particular aspect of cardiac surgery, such as paediatric cardiac services, to you at this time, 1991/92, that you would have suggested the same professional route, that is an appraisal by outside independent experts?
`A. Depending on who said it, I would have either suggested it or enacted it, if you follow me. It depends who said what to whom. If anybody had brought to my attention a concern about quality, then I would have referred that to those who could advise me. Could I remind you, I was a Fellow of The Royal College of Radiologists and had been on their Council, and I was quite accustomed to the responsibilities of Royal Colleges for quality. I would have had no difficulty and no hesitation to use the Royal College as the assessors of quality, and not management.' [82]
69 Counsel to the Inquiry asked Mr Peter Durie, Chairman of the United Bristol Healthcare NHS Trust (UBHT) from April 1991 to June 1994, about Miss Hawkins' letter of 20 November 1991. Mr Durie said there was pressure on the South West providers in relation to the volume of cardiac operations, but that he did not recall problems of quality of performance:
`Q. I think you have had a chance to see this letter, have you not, Mr Durie? This is the letter from Catherine Hawkins to Dr Roylance?
`Q. When did you first see this letter?
`A. I think I saw it for the first time yesterday.
`Q. Forgetting about actually seeing the physical piece of paper, were you aware that Catherine Hawkins was expressing views of this nature in 1991?
`A. I certainly do not recall it, but I could well have been told at the time. It would not have been of the greatest surprise, because if you look, what she is complaining about in that letter...: "... how poorly Bristol Trusts are now performing on cardiac surgery contracting". It was known that the South West had traditionally put less money into cardiac surgery than the country as a whole, and therefore, there was not the facilities to undertake all the operations that if the rest of the country was right, should be occurring in the South West. So there were pressures on the provider because the provider was not apparently saying "Yes, send all your people" because they did not have the facility to do it, so far as I know.
`Q. So there is a complaint about not enough operations being done?
`Q. If you look in the third paragraph, the last sentence: "I would more than welcome your comments and action if you feel you are not in sympathy with the current rate and quality of the performance of the cardiac unit." That is a different point, is it not?
`Q. So you would have been aware of that point as well?
`A. I am not sure. As I say, I did not see the letter and I am not sure what I was told. ... There were ongoing problems and debates between purchaser/provider all the time. I do not recall being told it, but equally well, it could have been something the Chief Executive felt he need not tell me.' [83]
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Footnotes
[63] UBHT 0038 0430; letter from Miss Hawkins to Dr Roylance dated 20 November 1991
[76] UBHT 0038 0426 - 0428 ; letter from Dr Roylance to Miss Hawkins (emphasis in original)