Annex A > Chapter 7 - Supra Regional Services > The SRS system in operation > Plans for a new Welsh Cardiac Unit and its effect on supra regional services (SRS)
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Plans for a new Welsh Cardiac Unit and its effect on supra regional services (SRS)
95 Meanwhile, developments were taking place in Wales that might have been seen as jeopardising further the number of operations carried out on paediatric patients. They had their origin in January 1984, shortly before Bristol's designation as a supra regional centre took effect, when, according to Mr Gregory:
`... the Secretary of State for Wales announced plans to provide a Regional Cardiac Centre for adults at the University Hospital of Wales site in Cardiff. The Working Group of the Project Team established by the Welsh Office and South Glamorgan Health Authority agreed that Paediatric Cardiac facilities should be provided immediately as part of the centre.' [86]
96 The Welsh Office had to give `Approval in Principle' to the plans of the South Glamorgan Health Authority (South Glamorgan HA) for the new cardiac unit. The Health Authority made its submission for such approval in June 1986. [87]
97 The `Approval in Principle' (AIP) document set out the aspirations of the South Glamorgan HA for a comprehensive paediatric cardiac service. It was, in effect, a proposal to the Welsh Office for support, that is, funding for a new service.
98 The South Glamorgan HA submitted that a `comprehensive paediatric cardiac service' was needed in Cardiff. [88] Mr Gregory stated that:
`In referring to a comprehensive paediatric cardiac service the authority included provision for neonates and infants under 1 year.' [89]
99 The submission described the then current (i.e. June 1986) paediatric cardiac facilities provided in Wales thus:
`Facilities in Wales for the investigation and surgical treatment of children with heart disease exist only in Cardiff and are scant. No beds are specifically allocated to paediatric cardiology, children being accommodated on general paediatric wards in the University Hospital of Wales as need arises. The cardiac catheter room facilities are shared with the adult cardiology workload. Paediatric cardiac surgery is subject to the same constraints as adult cardiac surgery. There is no full-time paediatric cardiologist; the service is at present provided by one consultant practising both adult and paediatric cardiology.' [90]
100 The AIP submission estimated the needs of a Welsh service as follows:
`The need to develop paediatric cardiac services in Wales is agreed. It is necessary for the clinical service to the patients in Wales, for the training of general paediatricians and of cardiologists in Wales, and to provide for expertise in managing congenital heart disease in adult life. The need is for a comprehensive service.
`The development of a less than comprehensive paediatric cardiac service would not in fact attract a paediatric cardiologist. A paediatric cardiologist will not be attracted without a full paediatric cardiac surgical provision, which necessarily requires a fully trained paediatric cardiac surgeon (including neonatal work). In practice therefore we have either a full paediatric cardiac provision or none.' [91]
101 Thus the submission was for a full cardiac service, including neonatal and infant work. The main proposals that the Health Authority made were:
`The paediatric cardiac service should be established as soon as possible because of the urgency of the clinical need. This requires the appointment of a paediatric cardiologist (trained in general paediatric and neonatal work), a paediatric cardiac surgeon (trained in neonatal surgery) and a paediatric cardiac anaesthetist. Close teamwork is required and it is appropriate to take advantage of the unique opportunity for a linked appointment of well suited individuals. One of the present cardiologists should continue to fulfil part-time the role of a second paediatric cardiologist until he retires; this component of his work should then be taken on by a second paediatric cardiologist. One of the present cardiac surgeons will fulfil the role part-time of a second paediatric cardiac surgeon. The paediatric cardiac work will be shared between the newly appointed anaesthetist and one of the present anaesthetists, each of whom will carry out some other duties. This practical compromise provides for less than 2 full-time paediatric cardiologists, at least in the short term, and less than 2 full-time paediatric cardiac surgeons, but is the appropriate provision, given the size of the catchment population.' [92]
102 It was not envisaged that the paediatric cardiac surgeon would be dedicated solely to paediatric work. This is demonstrated by this passage from the AIP submission:
`The paediatric cardiac surgeon will be fully trained in all aspects of his subject. He will also undertake some adult cardiac surgery, both as a contribution to the service and to ensure adequate continuing experience in relevant aspects of cardiac surgery (e.g. valve replacement).' [93]
103 At a national level, developments in surgery caused consideration of the SRS's strategy. The Decision Paper for 1986/87 [94] highlighted the development whereby the number of patients under 1 year receiving surgery was rising slightly because of increasing medical preference for early surgery.
104 The SRSAG saw no need to change NICS provision `over the next three years', but recognised the need for more work `to refine the methodology used for costing the provision of the service.' [95]
105 In early 1986 Harefield Hospital applied for designation as an SRC for NICS. There were also two other possible applications for designation (from Leicester and Hammersmith Hospital) and, in April, the Department requested advice from the RCSE and RCP.
106 The Colleges set up a Joint Working Party under the chairmanship of Mr Terence English (consultant cardiothoracic surgeon). Mr English (later to be knighted and to become a member of the SRSAG from 1990-1992, when President of the RCSE) wrote to the nine centres on 16 June 1986, seeking information. The information sought concerned the total numbers of closed and open cardiac operations performed on neonates and infants up to the age of 1 year in the calendar years 1984 and 1985. Mr English ended his letter:
`I should stress that information on mortality is not being sought.' [96]
107 The `Report of the Joint Working Party', dated 1 September 1986, deals with the situation in general, but had comments on some of the centres. [97] Among the recommendations were that the use of the designated SRC system continue (it was deemed be `essential') and that no more than nine centres were currently justified, although Harefield's application should be reconsidered in two years. [98]
108 Paragraph D of the report's recommendations stated:
`The Working Party noted that three Units, namely Bristol, Newcastle and Guy's were doing fewer operations per year than desirable for a supra regional centre. Bristol and Newcastle have legitimate claims for development on geographical grounds and should be encouraged ... The workload of these three centres and Harefield should be reviewed in two years' time.' [99]
109 At the same time that the Working Party was deliberating, the SWRHA received a report on `District Strategies for NICS for 1986/1994' from Southmead DHA and Bristol and Weston DHA. [100]
110 The view of the Department at the time was that encouragement of Bristol was to be welcomed. Mr Hurst, Secretary of the SRSAG, put it in his letter of 27 October to Dr Pitman, Specialist in Community Medicine at the SWRHA:
`We are anxious to do what we can to encourage referrals from Wales because we would like to see activity levels in Bristol rise ...' [101]
111 This approach appeared to be at odds with that reflected in the AIP submission made by the South Glamorgan HA, since the latter plainly had the capacity to reduce, rather than increase, referrals from Wales were it to be endorsed.
112 On 2 September 1986 the Welsh Office and South Glamorgan HA met to discuss the AIP submission. The minute of this meeting is short and was described as `terse' by Mr Gregory in oral evidence. [102] It said:
`... it was acknowledged that the Approval in Principle Submission would require revision.' [103]
113 The AIP had the strong support of a leading cardiologist, Professor Andrew Henderson, University of Wales Hospital, Cardiff. He was described by Mr Gregory as:
`... a man of significant expertise and considerable influence in the development of cardiac services. He was a leading contributor to the Welsh Medical Committee report of 1981, and he was ... a leading advocate, perhaps the leading advocate in Wales for the development of a comprehensive Welsh cardiac service.' [104]
114 Professor Henderson described what he saw as the inadequacies of the paediatric cardiology service then available in Wales. Dr Leslie Davies provided a clinic in Cardiff (and in some District hospitals), [105] but was by then ill and he died towards the end of 1986. Additionally, some cardiologists from London provided clinics in Wales. Professor Henderson said:
`We have not been able to provide the constantly available, co-ordinated expertise at an acceptably near centre for the South Wales population that is needed for present practice. LGD's [Dr Davies's] present illness has converted an increasingly inadequate service to what is now a potentially dangerous situation.' [106]
115 Professor Henderson prepared a document in support of the AIP submission, dated 2 September 1986. He emphasised that in his view advances in surgery and in non-invasive investigations were responsible for increasing numbers of neonatal and infant cardiac operations being carried out. [107] He thought this was a trend that was likely to continue, and he doubted that the previous assumption of 8.5 open-heart operations on infants under 1 per year per million population was still appropriate in 1986. His views were:
`The paediatric cardiac surgical workload actually undertaken in a region of comparable size to the population under consideration for Wales is now of the order of 60 to 65 (40%, i.e. 25, infant) open heart plus 35 to 40 closed heart operations per million per year (Southampton data for Wessex region, population 2.2 million). This implies 130 to 140 (ca. 55 neonatal) open heart plus ca. 80 closed heart operations per year for the Welsh centre. It represents a three-fold increase in infant surgical numbers compared with earlier estimates of 8.5 infant (under one year of age) open heart operations per year per million population (2nd Joint Colleges' Report, 1980).
`Earlier estimates of need have thus changed very considerably as the specialty has evolved and there has been a major shift towards corrective surgery in the neonatal period. The proportion of neonatal operations is likely to continue rising.' [108]
116 Professor Henderson estimated the occurrence of congenital heart malformations to be between ten and 13 per 1, 000 live births. [109]
117 Mr Gregory was asked about this figure.
`Q. The advice that you had as a Department was that it was not 12 to 13, it was 8 at most?
`Q. If that is right, then this is an overstatement by someone who is arguing the case, is it?
`A. Yes, I think that is how you could interpret it, certainly.
`Q. It must follow, if one was interpreting this from a Welsh Office point of view, looking at the question of the viability of the service in Cardiff at this stage, that one would see it as being necessary in order to establish a case for paediatric neonatal and infant cardiac surgery, that one would have to, as it were, stretch the elastic around the figures, to justify such a unit on number grounds?
`A. I think that is what lies behind it, certainly, but just to make clear, Professor Henderson was in a significantly professionally influential position, and one was not casting doubt on the sincerity with which he held these views, it just seemed to the Department that the evidence it had from other sources pointed to a different conclusion.' [110]
118 A meeting of the SRSAG took place on 2 October 1986, when the Joint Working Party Report of 1 September 1986 was considered and it was recommended that:
`... the workload of Newcastle and Bristol in relation to cost be monitored and efforts to expand workload in those centres be encouraged.' [111]
119 The minutes of this meeting [112] record that the joint Royal Colleges' Report argued that the incidence of congenital heart defects was likely to remain static, because the development of early inter-uterine detection of problems through the use of foetal echocardiography tended to lead to termination of those pregnancies with problems, which counterbalanced any increase in the birth rate. This argument was contrary to Professor Henderson's view that there was an increasing need for neonatal and infant cardiac surgery for a given population.
120 The SRSAG meeting was unpersuaded of the case for NICS in Cardiff. The minutes recorded that:
`It would appear from the argument in the report that there is little justification in establishing a centre in Cardiff for the management of a potentially limited number of babies with cardiac problems on grounds of doubtful clinical effectiveness and cost efficiency.' [113]
121 The deliberations of the SRSAG and its acceptance of the Joint Working Party Report had a major impact on the attitude of the Welsh Office to the suggestion that it should develop its own NICS in Cardiff. Diana Vass, a nursing officer at the Welsh Office, attended the SRSAG meeting in October 1986. [114] Subsequently, Mrs Vass sent a memo, dated 6 October 1986, to Ms J Roberts, who was a Principal in the Health Policy Division at the Welsh Office, reporting to Mr Gregory. It stated:
`I would suggest the most important comment is that we acknowledge a neonatal and infant cardiac service is available for Wales in Bristol - for which resources are protected and that Wales will continue to expect to use the supra regional service and will not be excluded from referring to that service.' [115]
122 The Welsh Office discussed matters at a meeting on 8 October 1986, chaired by Professor Crompton. In his statement Mr Gregory noted that:
`a) a supra regional centre had been designated in Bristol for the neonatal and infant service, whereas Cardiff was not so designated;
b) Bristol was at that time under-utilised.' [116]
`The meeting concluded that the cardiac development in Cardiff should be postponed until the results of an organisation and management study were known. The meeting also made it clear that the Supra Regional Advisory Group's ruling that children under 1 year old should be treated at the supra regional centre at Bristol should be supported.' [117]
`A supra regional centre had been designated in Bristol specifically for the neonatal and infant service, whereas Cardiff was not so designated. Provision at UHW for this service (included in the AIP) would therefore constitute duplication of the service available at Bristol for which the Welsh Office was paying indirectly. Bristol was presently under-utilised, undertaking approximately 50 operations per annum.' [118]
125 The meeting agreed that the initial development of cardiac services in Wales should consist of three stages, the first of which would be the setting up of a paediatric (i.e. over 1-year-old) unit. The second stage would be theatre provision and the third stage would be the upgrading of facilities for the main cardiac unit.
126 Thus the conclusions of the SRSAG as regards Bristol's continued designation and its desire to `encourage' work in Bristol, appears to have influenced the Welsh Office's attitude against the proposal that a neonatal and infant cardiac service be developed in Wales.
127 A meeting between medical officers of the Welsh Office and senior clinicians of the South Glamorgan HA took place on 20 October 1986. Mr Gregory's evidence about that meeting was:
`The DHA [sic] considered it would be unsatisfactory to send all neonatal cases to the supra regional centre at Bristol for treatment, mentioning the danger and distress endured in transporting patients over long distances, and the impracticability of Bristol paediatric consultants providing outlying areas in South Wales with a full service.' [119]
128 The other key influence was finance. The Welsh Office summarised the two key influences on the approach taken:
`a. the funds for the project were cash limited, subject to adjustment for inflation, and therefore costs had to be re-examined, neonatal provision being one element of the re-assessment;
`b. the recommendation of the Royal Colleges was clear and could not be ignored.' [120]
129 The meeting of 20 October 1986 decided that the Welsh Office Medical Group should report to the NHS Director for Wales, making the following points:
`a. ... that a formal request be made to the Royal Colleges of Physicians and Surgeons by the Welsh Office Medical Group for a sub-committee to provide a re-evaluation of the neonatal cardiac requirements for patients in Wales (Professor Henderson undertook to make preliminary approaches to members of the Royal Colleges committee);
`b. the project team would examine the costs of the whole scheme with a view to eliminating local additions and arriving at a properly costed scheme;
`c. Welsh Office should consider further the suggestion of the appointment of an independent project director ...' [121]
130 On 28 October 1986, Dr A George, the Deputy Chief Medical Officer (Wales), wrote to Dr Halliday. [122] In the letter Dr George requested the background papers which were considered by the Royal Colleges Joint Working Party in preparing its report of September 1986. He also stated to Dr Halliday:
`If Welsh Office is to hold a line on this type of work [this must refer to neonatal and infant work, since the letter is entitled "Neo-natal and Infant Cardiac Surgery"] being undertaken at Supra Regional Centres, Bristol is so designated for South Wales, we must have an assurance from you that it will not be closed and leave us without a readily available service.' [123]
131 Dr Halliday and the Department were willing to assist the Welsh Office. The RCSE, however, took a different view. In a memorandum of 10 December 1986, Dr Jennifer Lloyd, a Senior Medical Officer at the Welsh Office, wrote:
`... Terence English would not give permission for the Royal Colleges' Working Paper to be circulated. There seems to be a lack of communication between the Royal College of Surgeons and the DHSS on the issue of confidentiality of that paper.' [124]
132 Professor Crompton then wrote on 7 January 1987 to Mr Ian Todd, the new President of the RCSE, seeking the release of the Royal Colleges' Joint Report for consideration by the Welsh Medical Committee on 21 January 1987. Professor Crompton sought to exert considerable pressure on the RCSE, stating:
`It would be unfortunate if a unified approach between the Welsh Office and the Department of Health to the provision of neonatal and infant cardiac surgery could not be maintained because full information was only available to the advisory machine to one of the Departments of State.' [125]
133 Professor Crompton's approach appeared to have worked, since the Report was forthcoming in time for the extraordinary meeting of the Welsh Medical Committee of 21 January 1987.
134 In the meantime, whilst attempts were made to obtain the background papers, the Welsh Office Ministers had decided in November 1986 that in the light of the Joint Working Party's apparent endorsement of Bristol as a supra regional centre for neonatal and infant cardiac services, the proposed Welsh Unit should not include such services. This decision was reflected in a note from Mr Ivor Lightman, Deputy Secretary to the Welsh Office with responsibility for Health and Social Care, to Professor Crompton of 26 November 1986, which stated:
`Ministers made it perfectly clear at yesterday's Health Policy Board meeting that they accepted the advice from the Royal Colleges that neonatal cardiac surgery should be centred on Bristol with the Cardiff surgeons forming part of the "team" in the way you described. They also made it clear that having had the advice and having received decisions from Ministers we should now get on with it, which means making the position clear to the "opposition" and proceeding with planning on the basis agreed while recognising that we may well take some flak. Naturally, the Press Office and others will have to be warned about that.' [126]
135 In Bristol itself at this time, there was optimism that the number of referrals [127] from South Wales would increase. [128]
136 For the first two years of the SRS (1984 and 1985) there had been a meeting of representatives from the NICS SRCs hosted by the Department in London. Despite an initial suggestion that these meetings become an annual event, the Department now decided to discontinue them. As Mr Hurst put it in a circular letter of 30 October 1986:
`Our view is now that the service is sufficiently well established for these meetings to be no longer necessary; the Department is also under pressure to reduce meetings in order to effect financial savings, and I am sure that your time is valuable too.' [129]
137 Dr Eric Silove, consultant paediatric cardiologist in Birmingham, who had attended the previous meetings, wrote to the Department on 17 November, regretting the decision:
`I feel it is a pity that you are proposing not to continue with the annual meeting ... It proved to be a most helpful forum not only for helping establish the service but also for looking well into the future.' [130]
138 The `Decision Paper for 1987/88' [131] extended the funding arrangements by also introducing capital funding, with effect from that year. It was also recorded that the advice of the Joint Working Party to continue NICS as an SRS was accepted, `so that the necessary expertise can be concentrated in a limited number of centres.' [132]
139 Harefield and Brompton Hospitals had been added to the designated centres, but it was envisaged `that there would be little need for expansion in the total service.' [133]
140 In the interim, there had been a visit to Bristol by Professor Crompton and colleagues from the Health Professional Group of the Welsh Office, in the autumn of 1986. This arose because Professor Henderson had made critical comments about the performance of the Bristol Unit as part of his paper in support of the AIP submission, and Professor Crompton and his colleagues `... were motivated to explore for ourselves whether there was any substantiation of Professor Henderson's critical comments about the Unit'. [134] ( These critical comments are explored later, in reviewing concerns expressed about paediatric cardiac surgery at Bristol.) [135] The visit followed an earlier one made by Professor Crompton and his colleagues in about 1984, very shortly after designation.
141 Professor Crompton told the Inquiry that on both visits he met Dr Jordan and Dr Joffe and also Mr Wisheart. On the second occasion Professor Crompton and his colleagues briefly met Mr Dhasmana in addition. [136]
142 Following the visit, Dr Jennifer Lloyd, Senior Medical Officer at the Welsh Office, prepared a written report, dated 27 November 1986, summarising the results of the visit. Her report indicated that contact had been made by Professor Crompton and senior medical colleagues at the Welsh Office with the Department, with clinical and community medicine colleagues at the SWRHA, and at the BRI and BRHSC.
143 As to the visit to Bristol, Dr Lloyd's report said:
`The visit to Bristol disclosed that currently (April 1 1985 - March 31 1986) 40 cases from 3 health authorities in Wales had been treated at the Bristol Children's Hospital and 4 at the Bristol Royal Infirmary. Thus the Bristol Service is already providing a substantial part of the service need for this category of case. There is evidence in the past 6 months that 2 more health authorities are also sending cases to Bristol. It is interesting to note that the number of cases from South Wales referred is roughly equal to the number referred within South Western excluding Bristol and Gloucester.' [137]
`In frank discussions with the clinicians [i.e. in Bristol] there was a positive wish to increase throughput and continue the trend of improving outcome with the ensuing maintenance and developing of skills.' [138]
145 Dr Lloyd's report continued:
`On discussion with the staff it was made clear that the consultants providing the Bristol service accept and indeed welcome a commitment to provide the infant and neonatal cardiac surgery service for South Wales. They acknowledge the natural aspirations of clinical staff in Cardiff to provide the total paediatric service on one site but they point to (and can demonstrate by the Bristol service) the advantages in lower mortality and morbidity due to increasing expertise and adequacy of equipment that result from the greater throughput of cases.' [139]
146 It is not clear to which Bristol clinicians in particular Dr Lloyd is intending to refer. Nor does she explain what evidence, if any, was cited in support of the suggestion that there was a `trend of improving outcome' to `continue', nor whether this trend of improvement was said to be an absolute one and/or a relative improvement compared with other centres. Further, it is not clear by what evidence `the Bristol Service' can `demonstrate' the `advantages' referred to as resulting from `the greater throughput of cases'.
`We were unable to obtain from DHSS, who do not hold figures broken down by units, any figures on outcome by centre. 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.' [140]
148 It is not clear what, if any, further inquiry was made of Bristol by the representatives of the Welsh Office to seek justification for the argument based on case mix. It is not clear on what basis the implicit suggestion was made that the Bristol case mix was more difficult than elsewhere. The Welsh Office does not appear to have pressed for further information or explanation. Nor does it appear that further information was tendered to it.
149 The last passage quoted from Dr Lloyd's report includes an implied admission by the Bristol clinicians that their results, for less `commonly occurring conditions' did not compare well with other centres. The Welsh Office does not appear to have established what these rarer conditions were, and no steps were ever taken to suggest that patients with those conditions should be referred to units other than Bristol. Whilst it seems that the Bristol clinicians volunteered data on the commoner procedures, it appears that they were neither asked for, nor did they provide, data on the rarer conditions.
150 Professor Crompton told the Inquiry:
`I believe that the answers we got were honest and seemed to be full. The clear recollection I have is that we were told that indeed they knew that they could do better; that it was their intention to improve year on year; and that the local health authority, whether it was Bristol and Weston or the RHA, I would not know, had by 1986 greatly improved the fabric of the accommodation that was in the Bristol unit.' [141]
151 Dr Lloyd's report is consistent with the recollection of Dr (later Dame) Deirdre Hine, then Deputy Chief Medical Officer (Wales), of the 1986 visit. She stated in her written statement to the Inquiry:
`The discussions we had with both the clinical staff of the service and of the Regional Health Authority gave us no cause for anxiety. They indicated that the outcomes for the simpler operations were good and that those for the more complex procedures were improving as the throughput of cases increased. We were, however, unable to obtain any detailed statistical evidence for these claims.' [142]
152 In her December report Dr Lloyd reiterated what she had already stated in her previous report of 27 November 1986. Dr Lloyd expressed a clear preference for a policy of using Bristol for Welsh neonatal and infant cardiac work. Her December report said:
`The decision which has to be taken lies between 2 clear options -
`1. to provide self standing comprehensive paediatric cardiology and cardiac surgery based in Cardiff or
`2. to provide paediatric cardiology and cardiac surgery from Cardiff with the element of infant and neonatal surgery based in Bristol. This would be consistent with the views of the Supra Regional Advisory Group.
`The paediatric and cardiology and cardiac surgery services could most appropriately and effectively be provided for Wales on the basis of the second option. However, this would require careful implementation and planning ...
`We would wish to recommend that neonatal and infant cardiac surgery should be provided from Bristol on the basis of a joint service.' [143]
153 Following this report, an extraordinary meeting of the Welsh Medical Committee took place on 21 January 1987. The Welsh Office representatives at the meeting summarised the situation in this manner:
`i. Bristol currently offered the certainty of a service for infants and neonates.
`ii. Problems were apparent with the provision of adult services in Cardiff.
`iii. Difficulties were occurring in recruiting junior medical and nursing staff to work in South Wales, and were unlikely to be easily solved.
`iv. The Joint Working Party Report addressed itself to questions of quality, a difficult concept for small caseloads.
`v. Paediatricians in Gwent had explained that they were very satisfied with the service provided by Bristol.
`vi. Because it had been shown that quality of service was closely related to numbers dealt with in any one unit, there would be a danger of there being 2 "second rate" units at Cardiff and Bristol if the proposals being put to the Committee were accepted.
`vii. Infant cardiac surgery at Bristol might be less certain to continue after the 1989 DHSS Review if doubts were expressed over its service to South Wales patients.' [144]
154 At the January meeting, the Welsh Medical Committee heard representations from Professor Crompton, Dr George and Dr Lloyd on behalf of the Welsh Office and from Professor Henderson, Mr R C Williams, Mr Butchart and Dr Verrier Jones from South Glamorgan HA. Mr R C Williams argued that the Joint Working Party's conclusions in respect of supra regional services were of little or no application to Wales. Mr Butchart argued that Bristol appeared to have been designated as an SRS for geographical considerations, not because it was an existing centre of excellence, as had been the basis for designating the other supra regional units. [145]
155 The conclusions of the Welsh Medical Committee were:
`... the ideal solution would be for a comprehensive Paediatric Cardiology Service to be developed in Cardiff. However, it recognised that such a service would not be attainable for the foreseeable future, because of the absence of the necessary infrastructure, difficulties in recruiting appropriate junior medical staff and nurses, and reservations about the likely number of patients requiring this form of treatment. Consequently Neo-Natal and Infant Cardiac Surgery should continue to be provided from Bristol. It is further agreed that Paediatric Cardiology should be developed in Cardiff as a matter of urgency, with an immediate need for one Paediatric Cardiologist and a second to be in post as soon as possible.
`It is also advocated that close liaison should be established between the Paediatric Cardiology Service in Cardiff and the Supra-Regional Paediatric Cardiac Surgery Service in Bristol. In future, a review of the facilities in Cardiff would be necessary if demands increase with advances in diagnosis and surgical techniques.' [146]
156 The Welsh Office accepted this advice. Thus it was decided that cardiac surgery for children aged one year and above should be provided in Cardiff. [147] The Minister's private office (Welsh Office) said that the Parliamentary Under Secretary of State:
`... has noted the advice contained in Mr McGlinn's [Welsh Office] submission of 3 February. He agrees that the paediatric cardiac unit to be provided at Cardiff should not at present be developed to include facilities for neo-natal and infant cardiac surgery and that the Bristol unit should combine to provide the service for South Wales patients. The Minister has commented that in announcing this decision it would probably be wise to say that the matter will be kept under review in the light of future circumstances.' [148]
157 Thus NICS were excluded from the initial stages of the Cardiff development. Professor Henderson remained unhappy. The Inquiry received evidence that the Chairman of the South Glamorgan HA was under pressure from Professor Henderson:
`... not to restrict the freedom of clinicians to refer patients to those hospitals in which they have confidence.' [149]
158 In a note of 5 March 1987, Mr Gregory referred to Professor Henderson's continued concerns, and stated:
`... the DHA is looking to us to accept that although Bristol is the supra regional centre for South Wales, clinicians in Wales still retain the usual discretion to refer patients from Cardiff to hospitals of their choice.
`I am not sure what this means in practical terms. On the assumption that this is merely a face-saving exercise for Professor Henderson then I think we may be able to go along with it. If that is the case, all we need is a very brief letter of reply which does not open up the whole issue but does not resile from the decision we have already obtained from Ministers.' [150]
159 In December 1987 the Welsh Office asked the RCP to set up a task force to review cardiac surgery and cardiology in Wales, with a particular emphasis on NICS. It specifically requested that evidence be taken from Dr Halliday. [151] Clinicians in Bristol were aware that cardiologists in Wales had requested the view of the RCP earlier in the year and, on 3 August 1987, wrote to the RCP with their views. [152]
160 The Report of the Cardiology Committee of the RCP said that:
`The Advisory Group [153] is unanimous in reaffirming the importance of the development of the paediatric cardiac unit, already approved by the Welsh Office, to include paediatric cardiology and paediatric cardiac surgery, and this to be developed in association with the existing general paediatric department, neonatal unit, and regional cardiac and cardiac surgical centre. The Advisory Group considers that this unit should ultimately provide management for the whole of congenital heart disease. Presuming this concept is accepted, there is a need now to appoint a paediatric cardiologist, who should be expert in cardiac catheterisation, interventional techniques, and echocardiography. He should establish links with local paediatricians in South Wales who are anxious for this service, which should slowly be established. In addition a cardiac surgeon should be appointed as soon as possible. He should be capable of carrying out both paediatric and adult cardiac surgery. There is not the caseload at the present time to justify the appointment of a "pure" paediatric cardiac surgeon. These two new appointees will be the focus for the developments of the new service working to set up new lines of referrals and patterns of care.' [154]
161 The Committee further concluded that there was a need for:
`... about 100 paediatric cardiac operations per year. The Royal College considered that, in due course, the Cardiff unit should provide cardiac surgery for children under 1 year old.' [155]
162 On 22 January 1988 Paper SRS(88)2 was prepared for the SRSAG. [156] It discussed the current situation for NICS and, for the first time, one of the options was de-designation of the whole service. [157] The paper noted that:
`... returns from the designated units are concerned with quantity not quality, i.e. type of operation performed and mortality rates are unknown factors.' [158]
The Report identified that, based on a two surgeon unit, `... the minimum open-heart workload is likely to be at least 80 cases per year', and that, referring to Bristol in particular, [159] `Three of the designated units fall far short, i.e. Guy's, the Bristol Royal for Sick Children and the Freeman, Newcastle' and that `probably [those] three have a very small workload.' [160]
163 The Paper was discussed at the SRSAG meeting on 4 February 1988 and its recommendation was that the Society of Cardiothoracic Surgeons (SCS) be asked to comment and carry out a fact-finding survey, which it agreed to do. It was to advise on whether SRSs for NICS should continue at all. Sir Keith Ross, the then President of the SCS, was approached.
164 Additionally, Dr Halliday and Mr Alan Angilley, SRSAG Administrative Secretary 1987-1992, arranged to visit Wales to discuss current and future service needs for South Wales. On 24 February 1988 Dr Hine wrote to Dr Marie Freeman, Acting Regional Medical Officer for SWRHA. Dr Hine stated in her letter:
`I have drawn up the attached Agenda in which, as agreed with you, the two distinct elements, i.e. cardiac surgery under one year and cardiology at all ages together with cardiac surgery over one year, are distinguished from one another. We would be grateful to have any up-to-date figures available to you which illustrate the current demand from Wales on Bristol for either form of service. The latest figures I have relate to the period up to June 1986 and are for infant and neonatal cases only.' [161]
It was plainly the belief of the Welsh Office that the SWRHA was monitoring such numbers.
165 The visit to Wales took place on 7 March 1988. In a paper presented to a meeting held during the visit, by the DHSS, it was noted that there were `highly significant' differences in outcome between centres with high and low output. Bristol was described as `one of the smallest centres in terms of throughput.' It was `however seen as having a legitimate claim for development on geographical grounds and the consideration of this has included its proximity to the South Wales population.' [162]
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Footnotes
[86] WIT 0058 0006 Mr Gregory
[87] WIT 0058 0006 Mr Gregory
[88] WIT 0058 0006 Mr Gregory
[89] WIT 0058 0010 Mr Gregory
[90] WO 0001 0148; AIP
[91] WO 0001 0150; AIP (emphasis in original)
[92] WO 0001 0152; AIP
[93] WO 0001 0153; AIP
[94] UBHT 0278 0445; `Supra Regional Services, 1986-87'; Secretary of State's Announcement
[95] UBHT 0278 0447; `Supra Regional Services, 1986-87'; Secretary of State's Announcement
[96] RCSE 0002 0005; letter from Mr Terence English to NICS Centres, dated June 1986
[97] RCSE 0002 0009, 0012 -0013; `Report of the Joint Working Party', 1986
[98] Simultaneously, the conclusion of Professor Andrew Henderson reporting to the Welsh Office, was that `The recommendations for the 9 designated supra regional neonatal cardiac surgical centres in England were based on now outdated estimates of neonatal workload.' WO 0001 0230. Even after consideration of the `Report of the Joint Working Party', the SGHA still criticised its conclusions. WO 0001 0246
[99] RCSE 0002 0013; `Report of the Joint Working Party', 1986
[100] WO 0001 0123 - 0142 ; `District Strategies for NICS' 1986/94
[101] UBHT 0062 0213; letter from Mr Hurst to Dr Pitman, dated 27 October 1986
[103] WO 0001 0224; minute of meeting, 2 September 1986
[105] See Chapter 11 for the interrelation of these clinics with referrals to Bristol
[106] WO 0001 0226; report, 2 September 1986
[107] WO 0001 0225; report, 2 September 1986
[108] WO 0001 0225; report, 2 September 1986
[109] WO 0001 0231; report, 2 September 1986
[111] WO 0001 0234; minutes of meeting, 2 October 1986
[112] WO 0001 0234; minutes of meeting, 2 October 1986
[113] WO 0001 0235; minutes of meeting, 2 October 1986
[114] WO 0001 0224; minutes of meeting, 2 October 1986
[115] WO 0001 0238; memo dated 6 October 1986
[116] WIT 0058 0006 Mr Gregory
[117] WIT 0058 0010 Mr Gregory
[118] WO 0001 0242; minutes of meeting, 8 October 1986
[119] WIT 0058 0006 Mr Gregory
[120] WO 0001 0247 - 0248 ; minutes of meeting, 20 October 1986
[121] WO 0001 0249; minutes of meeting, 20 October 1986
[122] References to the Department of Health include references to the DHSS, prior to its separation into the Departments of Health and Social Security
[123] WO 0001 0250; letter from Dr George to Dr Halliday dated 28 October 1986
[124] WO 0001 0262; memo dated 10 December 1986
[125] RCSE 0002 0022; letter from Professor Crompton to Mr Todd dated 7 January 1987
[126] WO 0001 0253; note from Mr Lightman to Professor Crompton dated 26 November 1986
[127] The issue of referral patterns from Wales to Bristol and other parts of the country is dealt with fully in Chapter 11. The section on Wales within that chapter also deals with how resources were allocated for the funding of those referrals from Wales to Bristol
[128] UBHT 0062 0216; memo from Dr Ian Baker, Assistant General Manager (Planning)/District Medical Officer, to Mr Graham Nix, Senior Assistant Treasurer (Financial Management) at the B&WDHA
[129] ES 0002 0026; circular letter dated 30 October 1986
[130] ES 0002 0025; letter from Dr Silove to DoH dated 17 November 1986
[131] UBHT 0278 0377; SRS 1987-88 Secretary of State's Announcement
[132] UBHT 0278 0377; SRS 1987-88 Secretary of State's Announcement
[133] UBHT 0278 0378; SRS 1987-88 Secretary of State's Announcement
[134] WIT 0070 0004 Professor Crompton
[135] See Chapter 21
[136] WIT 0070 0004 Professor Crompton
[137] WO 0001 0257; Dr Lloyd's report, 27 November 1986
[138] WO 0001 0259; Dr Lloyd's report, 27 November 1986
[139] WO 0001 0259; Dr Lloyd's report, 27 November 1986
[140] WO 0001 0260; Dr Lloyd's report, 27 November 1986
[141] T21 p.47 Professor Crompton
[142] WIT 0297 0002 Dame Deirdre Hine
[143] WO 0001 0266; Dr Lloyd's report, December 1986
[144] WO 0001 0275; Dr Lloyd's report, December 1986
[145] WO 0001 0278; minutes of meeting, January 1987
[146] WIT 0058 0007 Mr Gregory; and WO 0001 0286 - 0287 Welsh Medical Committee
[147] WIT 0058 0008 Mr Gregory
[148] WO 0001 0291; note dated 10 February 1987 (emphasis in original)
[149] WO 0001 0294; note dated 5 March 1987
[150] WO 0001 0294; note dated 5 March 1987
[151] WO 0001 0317 - 0318 ; letter dated 15 December 1987
[152] UBHT 0133 0029; letter dated 3 August 1987
[153] WO 0001 0339; The Royal College of Physicians Advisory Group on Cardiac Services in South Wales. The Advisory Group's terms of reference were: `To provide medical advice to the Welsh Office on the provision of cardiology and cardiac surgery services to the population of South Wales (2 million)'
[154] WO 0001 0344 - 0345 ; Report of the Royal College of Physicians
[155] WIT 0058 0008 Mr Gregory
[156] DOH 0002 0240 - 0247 ; Paper SRS(88)2
[157] DOH 0002 0242; Paper SRS(88)2
[158] DOH 0002 0242; Paper SRS(88)2
[159] DOH 0002 0240 - 0247 ; Paper SRS(88)2
[160] DOH 0002 0242; Paper SRS(88)2
[161] UBHT 0062 0398; letter from Dr Deirdre Hine to Mr Angilley dated 24 February 1988
[162] UBHT 0062 0401; `Supra Regional Centres for Infant and Neonatal Cardiac Surgery', March 1988