Annex A > Chapter 6 - Funding and Resources > Resources > The relation between funding and clinical services
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The relation between funding and clinical services
`... I am not aware of any positive incentives in relation to the services offered that were created by the methods of funding paediatric cardiac surgery. Indeed, throughout my time first as District General Manager and then as Chief Executive, I was constantly seeking to persuade all clinicians that issues of funding of services mattered. The tendency during that period was for all those in the National Health Service to regard any purported or proposed financial restrictions on clinical activity as unacceptable, if not frankly immoral. This was the "culture change" referred to in the notes of the meeting of the Executive Directors Group held on 8 May 1991, [175] on which I have been asked to comment.
`As far as I am aware, throughout the relevant period, children referred to Bristol for care were accepted and treated solely on the basis of their clinical need, and were referred elsewhere if that was considered to be in their best interests.' [176]
`Throughout the period under review I, as District General Manager and then as Chief Executive, was repeatedly urged to effect an improvement in each and every service that we provided. I cannot now recall any specialty or department which did not press for improvements, usually requiring substantial sums of additional capital and revenue expenditure.
`The demands for improved facilities, etc. were very often expressed in exaggerated and emotive terms. I do not say this intending to be pejorative: people working in the health service have always been characterised by the strongest desire to do the very best possible for their patients and it is a source of very real frustration and distress to carers that what may technically be possible is often practically not available. Lack of funding for the maintenance, development or improvement of a service has always been one of the most frustrating problems within the National Health Service.
`I was committed to obtaining the maximum possible level of funding for the services we provided, and I believe that there was a strong culture within the Trust of creativity in the identification and securing of additional sources of income, led by Graham Nix as Finance Director. However, I have never seen overspending as an acceptable solution to the problem of under-funding: it was my responsibility to ensure that the District Health Authority and then the Trust provided the best possible care within the resources available. Indeed, during the selection process that led to my appointment, I was required to give a presentation on how, within a 5 year timescale, I would bring the Health Authority within budget. When I was appointed, the Appointments Committee made clear that this was my primary responsibility.
`Once the budget had been set, therefore, I could not allow it to be exceeded. However, I know that elsewhere in the NHS overspending sometimes occurred and I am sure that the fact that from the year after I took up the post of DGM we remained consistently within budget was sometimes a source of additional frustration to those clinicians that saw other Authorities and Trusts "getting away with it", although I believe that we had done much to change the culture within the Trust, as I set out in my statement on Issue B.
`It is against this background that requests were repeatedly made over a number of years for improvements in the provision of paediatric cardiac surgery. Unfortunately, this fact alone did not distinguish this service from any other. One of the tasks of a District General Manager was to balance the competing needs of all the services within the District, and with the introduction of contracting it became harder to find "spare" money for ad hoc projects. Cross-funding was not permitted, so that savings made in other areas of the Trust could not be used for paediatric cardiac surgery: the funding for the improvements had to come from cardiac surgery itself.' [177]
`I had been aware for some time that paediatric cardiac surgery was not achieving its full potential. The experts in the field were all agreed that UBHT needed to appoint a dedicated surgeon for the paediatric work and move the surgery to the Children's Hospital. The necessary management action had therefore been identified and work was being done to achieve both of those aims. In the financial climate of the time, where budgetary constraints were many and cross-funding of services was expressly prohibited, it had proved extremely difficult to identify the necessary funding.' [178]
127 Mr Baird commented, in his written evidence to the Inquiry, on the change to trust status:
`Dr Roylance had to push us into functioning as a Trust in the first wave. Initially there were the advantages of flexibility and leading the way. Trust status was achieved against opposition from many doctors in Bristol. However, the subsequent development of the NHS has proved that his decision to make us a first-wave Trust was a wise one.
`The theme was that money followed the patient thereby bringing business values to the NHS. There was resistance to this: staff simply wanted money to develop their services, as had been the traditional way of working.' [179]
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Footnotes
[175] UBHT 0240 0742; notes of the meeting of the Executive Directors Group, 8 May 1991
[176] WIT 0108 0003 Dr Roylance
[177] WIT 0108 0118 - 0119 Dr Roylance
[178] WIT 0108 0127 Dr Roylance
[179] WIT 0075 0008 Mr Baird