Annex A > Chapter 6 - Funding and Resources > Resources > Equipment
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Equipment
160 Mr Wisheart, in his written evidence to the Inquiry, described the availability of equipment:
`A post-cardiac surgery ICU requires a substantial amount of expensive equipment. This equipment also tends to become increasingly developed and sophisticated with the passage of time. The cost of such equipment was a challenge and often a problem. The sources of money to purchase equipment were as follows:
- `At a time of significant or major development such as 1987-88 when the Ward was totally refurbished, we obtained replacement of a substantial amount of our capital equipment.
`DISTRICT/TRUST MAJOR MEDICAL EQUIPMENT BUDGET:
- `For the renewal of equipment from year to year we had to compete with other demands for equipment within the Trust. It was common for the total cost of requested equipment to exceed the total of money available by a considerable factor.
`DEPARTMENTAL DISCRETIONARY FUNDS:
- `Patients and families who were treated in the Unit often gave donations, sometimes significant ones and it was possible to purchase equipment using this money.
- `If there was a totally unexpected breakdown in the function of vitally important equipment then the Trust kept a reserve fund which could be used to enable the work to continue.
`While there were times when we felt that we were well equipped and had the resources to replace equipment as we wished, there were certainly other times when we felt we were unable to replace old equipment when this should have been done. This was another reflection of what appeared to be reality, namely that the resource available to us fell far short of the demands that were placed upon us.
`When we became a sub-directorate in 1991, Ms Lesley Salmon and I began to compile a list of our equipment, its age, expected life and cost, as a first step in the development of a programme of regular replacement.
`To the best of my knowledge, we never undertook surgery when there was not functioning and safe equipment available to meet the needs of the patient who was being cared for. As an example, if there was no suitable ventilator available for the patient, then the operation would have to be postponed.' [224]
`We struggled to acquire suitable echocardiography equipment during the early 1980s, and it was only though the financial support of charitable organisations that we were able to purchase a 2D echocardiography machine in about 1984, and a second in about 1989. The situation improved after Trust status, when we acquired our third machine, in lieu of the outmoded first apparatus. We were always short of cardiac technological staff and, throughout 1984 to 1995 we shared technicians with the adult cardiac catheterisation service at the BRI. It was only in this way that we could ensure that, for emergency catheterisation after hours, there would be someone on call who was familiar with the BCH equipment. The paediatric cardiologists performed all echocardiography procedures themselves until the late 1980s, when we were able to appoint our first echocardiographic technician with financial help from the Paediatric Oncology Department for whom we provided a regular service. In the early 1980s, the paediatric cardiologists reported on all angiograms as part of the cardiac catheterisation reports. This was taken over by Dr Wilde in the mid 1980s, and his overall advice and assistance was most welcome. By the early 1990s, he became overwhelmed by the demands of adult cardiology and was no longer able to participate in the angiographic procedures himself, but still reported on the angiograms.' [225]
162 Dr Geoffrey Burton, consultant anaesthetist, [226] stated:
`... some centres (e.g. Great Ormond Street) had much more equipment sourced from generous charity monies, whereas we had to work on a much more restricted budget and had relatively little money sourced from charities ...
`In Bristol, we were only paid for three sessions to cover a day of cardiac surgery -frequently this did not even cover the time spent in the operating theatre, let alone continuing care for several days in the Intensive Care Unit. We were working on a very "tight" budget and it was not unusual for me to work for over 80 hours in the week and be paid for only 371/2 of them.' [227]
163 As regards equipment, Mr Wisheart stated:
`The equipment in operating theatres is fairly well standardised and is very similar from one hospital to another. This includes the basic operating theatre equipment such as tables, lights, diathermy, anaesthetic equipment such as ventilators, the surgeon's equipment such as instruments and the perfusionists equipment, the bypass machinery. The patient's life is dependent upon many items of equipment working reliably and effectively; therefore they must be well maintained.
`The main variability is that equipment and instruments are constantly evolving. Any given surgeon or institution will buy the newer equipment either sooner or later; there are often financial issues involved. However, these changes tend to be incremental rather than truly decisive in nature.' [228]
`Lack of capital investment was clearly reflected in the state of the equipment that was available in the Directorate. Much of this seemed to be reaching the end of its life span, with frequent need for maintenance and repairs. There was no rolling replacement programme for capital equipment. This seemed to be a particularly acute problem because cardiac services is such a high tech area of work, with some very complex and expensive equipment in use. (For example, to equip a new catheter laboratory might cost in the region of £1 million, which would be a substantial proportion of the Trust's capital budget for the year.) Work had been undertaken to devise a rolling programme for replacing equipment in a planned way, to try to ensure that the equipment did not let us down in providing a high level of service to patients, and I wanted to build upon and give greater emphasis to this. I was not very familiar with much of the equipment and was assisted by Dr Pryn and Fiona Thomas.' [229]
165 Dr Pryn stated that when he arrived at the UBHT, he took an active interest in the nature and state of the equipment that was available to him:
`Despite relatively old equipment, this was sufficient for full compliance with the standards proposed by the Royal College of Anaesthetists (Guidance for Purchasers 1994) and Association of Anaesthetists Recommendations for Standards of Monitoring during Anaesthesia and Recovery 1994. The one area of monitoring that was not available was capnography. [230] There were no capnographs present in the cardiac theatre suite when I joined BRI in 1993. It was felt that this was acceptable, although not ideal, as (i) fixed volume ventilators with expired volume monitoring were used in theatre and (ii) the blood gas analyser was readily available in the theatre itself. New theatre monitors, with the capability of capnography, were purchased in 1995, and around the same time capnography became available in the anaesthetic room as well. ...
`When I arrived at the BRI I found that much of the equipment, both in theatre and in the intensive care unit was old, and there were no mechanisms for replacement. I assumed responsibility for the co-ordination of equipment purchase. Document UBHT 0084 0101 is the list of "minor" equipment which I identified as being required. There was, in addition to this list, a list of major equipment. By way of example the syringe pumps in use in theatres had a number of problems. The replacement product which I recommended was purchased.' [231]
`... I would say that it is not quite right that "there were no mechanisms for replacement".
`There was a clearly defined mechanism for the replacement of major medical equipment. This involved undertaking a bidding process and completing an application form by 30 September each year for items of capital equipment over the value of £15, 000. These bids were meant to be prioritised within the Directorate and then considered by the Trust's major medical equipment committee. A decision would be made about these bids by December of the same year or January of the following year.
`The main problem as I saw it, was that despite this clear mechanism, the Trust had insufficient capital to meet the demands made upon the major medical equipment committee. In particular the decision to build the new Children's Hospital had led to a situation whereby £1.5 million of capital per annum had to be put aside for the Children's Hospital. As a consequence, the major medical equipment committee only had around £1.5 million per annum to spend on large capital items. As I said in my statement, the cost of capital for Cardiothoracic Services was very high, and it was clear to me that it was not possible to meet a rolling programme of the replacement of capital equipment through the major medical equipment committee.'
`As far as minor medical equipment was concerned there were mechanisms for bidding for equipment, but these were inconsistent.' [232]
168 As regards the absence of capnography monitoring equipment, Dr Pryn told the Inquiry:
`There must have been other institutions that did not have capnography throughout, but in an area like cardiac surgery, where it is extremely technical, you would have expected the state-of-the-art monitoring, and clearly this was not state-of-the-art.' [233]
169 He responded in the following exchange:
`Q. Is that a fair summary of your impression of the equipment in Bristol, that it was adequate but it would not be state-of-the-art?
`A. Yes. Fair.' [234]
`... an ongoing battle and "battle"is the right word, because you are competing with other departments in the hospital for very limited funds, and some of the wording on this document [235] is specifically coloured to paint the picture - a more dramatic picture than perhaps was necessary, just so we could have our voice heard. It is a battle to get money.' [236]
171 Dr Pryn told the Inquiry that the cardiac surgical unit at the BRI when he was appointed as an intensivist in August 1993:
`... was a unit that was often run minute by minute by relatively inexperienced doctors, with their senior cover not being that available, and it was a unit run by trainees who were not used to general intensive care issues, were quite familiar with managing the cardiovascular system, but were relatively poor at integrating that with the other systems, for instance, the respiratory system. ... Their background was not in general intensive care.'
He told the Inquiry that he felt that more input was required from staff with a general intensive care background, and that senior cover needed to be more available. It was an awareness of this, he said, that had fuelled his own appointment and that of Dr Ian Davies. [237]
172 The Inquiry's Expert, Dr Michael Scallan, consultant anaesthetist, Royal Brompton Hospital, commented on the points made by Dr Pryn in the following exchange:
`The shopping list we see here is the sort of shopping list that you see in many hospitals. There is a constant need to upgrade equipment, to replace equipment. A lot of the equipment that we use these days does not have a life really of more than ten years, and you have to think of moving forward to the next generation of equipment.
`So what we see here is a very fair shopping list.
`Q. If we had gone into other NHS units across the UK performing paediatric cardiac surgery at about this time, are we likely to have seen similar issues about the replacement of machines of this nature?
`A. Yes. I think that is a fair comment, yes.
`Q. So there is nothing here that strikes you as being out of the ordinary in terms of the needs of this particular unit?
`A. I think the section on the equipment in the theatres and in intensive care does suggest that that equipment should have been replaced a little earlier. I think that was the middle 90s. What was in existence does appear to have been rather old equipment and quite correctly the need to upgrade it - the case for the need to upgrade it was made in this list.' [238]
173 When Dr Scallan referred to equipment being unavailable at his hospital, the Chairman of the Inquiry explored the point in the following exchange:
`Q. (The Chairman) You say that you encountered some of the same difficulties. Would that persuade you to say that therefore one can say that whatever was provided at your institution or at Bristol was adequate and appropriate, or does it persuade one to say that against a different standard, a slightly more absolute standard, neither were up to snuff?
`A. (Dr Scallan) To answer that question in a slightly indirect way, I think the standards are evolving all the time and as new equipment becomes available and becomes used, so it creeps into what is considered basic monitoring, or basic standards. So in an ideal world, you could say that both institutions were short of the ideal standard.' [239]
174 In January 1992, the first of the `recommenced' audit meetings of paediatric cardiology and cardiac surgery reviewed the audit topic `closure of the patent ductus by a transvenous insertion of the Rashkind device' in 24 cases. Conclusions were reached upon the most appropriate procedure. The note of the meeting read, under the heading `Action Taken/Clinical Changes Instituted', `Unable to implement due to lack of finance... Cost £1783 + VAT more than for cardiac catheter.' [240]
175 Dr Roylance was asked by Counsel to the Inquiry to comment on this note in the following exchange:
`Q. On the face of it, this is a document which - I may have to ask those more closely connected with the delivery of the cardiac service about it, but this is a document which might suggest that a lack of finance was preventing the delivery of optimal care.
`Q. Have I misunderstood or not?
`A. No, I mean, I believe you have not misunderstood.' [241]
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Footnotes
[224] WIT 0120 0216 - 0217 Mr Wisheart
[225] WIT 0097 0306 Dr Joffe
[226] Dr Burton was appointed as lecturer, Department of Anaesthesia in the University of Bristol, in 1959. His clinical practice covered both the BRI and the BCH until the summer of 1991
[227] WIT 0555 0004 - 0005 Dr Burton
[228] WIT 0120 0172 Mr Wisheart
[229] WIT 0089 0013 Rachel Ferris
[230] Capnography is the measurement of exhaled carbon dioxide values
[231] WIT 0341 0021 - 0022 Dr Pryn
[232] WIT 0341 0100 Rachel Ferris
[235] The list of minor equipment which Dr Pryn prepared
[240] UBHT 0061 0156; minutes of meeting on 22 January 1992. See Chapter 18