Annex A > Chapter 7 - Supra Regional Services > The SRS system in operation > De-designation of NICS
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De-designation of NICS
216 In the event, the SRSAG decided to de-designate the whole NICS, stating that this was `a fairer decision in terms of medical and surgical rights of patients than to restrict designation to a few surgical units.' [236]
217 On this point Sir Michael was asked:
`Q. One of the difficulties that we have in making sense of what is said there is that the thesis, up until now, and the advice, has been that it is in a patient's best interests that there should be a designated service. It is contrary to a patient's interests that there should be proliferation of services, and it would be desirable to use whatever efforts one could, within obviously the limits of time, to restrict proliferation of services?
`Q. One appreciates that there may have to be a bowing to the inevitable, but is there any particular reason that you can help us, why is it described as a "fairer decision in terms of the medical and surgical rights of patients" than the continuation of a system with sufficiently few designated units to achieve the objects of the system?
`A. I have a little difficulty with that, in retrospect, I have to confess. I think it goes back to the proximity of service, the geographical element. I am sorry, I cannot help you more than that. I find it a slightly ambiguous paragraph myself, in retrospect.' [237]
218 Sir Terence said that he was unable to understand the logic of the reference to `fairer in terms of medical and surgical rights'. [238]
219 This same point, about fairness, was put to Mr Steven Owen:
`I find it difficult to answer that question after this period of time, frankly, but I think it is simply a recognition that the nature of the service had changed, proliferation was widespread, and it was simply accepting reality. I think the de-designation decision itself was an acceptance of reality.' [239]
220 Sir Michael was asked whether matters would have taken a different course had the Working Group recommended a greater reduction in the number of centres being funded by the SRSAG for NICS:
`Q. Suppose that Professor Sir Terence English's Working Party had come up with the suggestion that there are six names, six centres, which the Royal College recommended for continuing designation. Do you think that probably the Advisory Group would have said, "Okay, we will retain designation for those six"?
`A. I think it is highly likely.
`Q. So it follows, does it, that the real problem or the real cause of de-designation of the service was not the fact that it was a mature service and was not the input from Guy's, it was simply a function of numbers?
`A. It was proliferation.' [240]
221 In his supplementary statement of 18 December 1999, Dr Halliday said that:
`... my assessment of the likely outcome of the Supra Regional Services Advisory Group meeting [on 28 July 1992] was that the NICS service would be de-designated. The [SRSAG] had no alternative. In such circumstances Sir Terence's reservations were not important. Of course I had no way of knowing how serious these reservations were.' [241]
`Had the NICS service continued to be designated but Bristol was to have been de-designated then Sir Terence's reservations would have been extremely important and the [SRSAG] would have wished to know in detail what these reservations were. I would therefore have been pressing Sir Terence for details. In the context of the [SRSAG] meeting however the details of Sir Terence's reservations were irrelevant.' [242]
223 Dr Halliday saw July 1992 as the end date of SRSAG's involvement with NICS:
`A. ... It was de-designated in 1992. It was funded for two years after that, but that was not a matter for the Advisory Group.
`Q. It remained, did it not, the responsibility of the Advisory Group?
`A. No, it did not, no.' [243]
224 Professor Hamilton wrote to Sir Terence on 3 August 1992. It appears from the letter that Professor Hamilton and Sir Terence had spoken twice, in July 1992, some days prior to the SRSAG meeting, and that Professor Hamilton had also spoken to Sir Keith Ross (a fellow member of the Working Party) on the morning of Monday 27 July 1992. Professor Hamilton said in the letter:
`I hope that you had a highly successful trip to and safe journey back from Pakistan, and are refreshed after a demanding but successful term as President.
`Following our telephone conversations of Thursday evening, July 23rd, and Friday afternoon, 24th, I was not entirely happy about our agreement to take Presidential and Chairman's action over the Working Party's report. On reflection, I realised a possible specific source of "breach of confidentiality" which could arise, and a further feeling that the de-designation of one of the units would probably "leak out" in the course of time. Also, the members of the Working Party were unanimous in their findings and gave considerable thought to their recommendations. Like you, I was unable to contact Keith Ross but did so early on Monday morning, the 27th, after he had returned home from holiday. He was equally concerned that we had changed the report and suggested, on reflection, that we should both speak with Norman Halliday to reverse the decision and the instructions that you had given him.
`... the Working Party could be requested by the Advisory Committee on supra regional funding to reconsider the mortality figures of specific units (or unit), and possibly to amend its findings.' [244]
225 Sir Keith gave written evidence to the Inquiry. He said:
`It is safe to say that when David Hamilton telephoned me at home on 27th July 1992, when I had just returned from Scotland, I had no idea of the events leading up to the telephone call. I am sure David Hamilton did his best to explain the sequence of events, but under the circumstances (and I have no clear memory of the conversation), I must have agreed with his concern regarding the working group's conclusions being altered. Whether he or I suggested telephoning Dr Halliday is immaterial, but he had to be given our views. There was no way that I could have talked with Terence English who was either in, or on his way to, Pakistan, nor was there time to reconvene the working party before the SRSAG meeting, which was due the next day or the day after ...
`Finally, I have no recollection of suggesting to Dr Halliday that the Working Party could be requested to reconsider the mortality figures of specific units with a view to possibly amending its findings. I would like to think that I would have recommended this, but as explained above, this never happened.' [245]
226 When he was shown Professor Hamilton's letter of 3 August 1992, in the course of his first appearance at the Inquiry, Dr Halliday said:
`This letter changes the whole context. My discussion with Sir Terence, or at least his discussion with me about his concerns about Bristol simply meant that he had reservations about Bristol and therefore he was not entirely happy with the report from the College.
`This letter would suggest that there appears to be more to it than that, and I cannot comment on that.' [246]
227 Dr Halliday accepted that the letter suggests that the discussions between Professor Hamilton and Sir Terence had involved the issue of mortality findings. [247]
228 Sir Michael Carlisle was emphatic that he had no knowledge of the contact between Professor Hamilton, Sir Keith Ross, Sir Terence English and Dr Halliday and knew nothing of the discussions suggesting alterations to the Working Party's report. [248]
229 After returning from Pakistan and learning what had occurred at the meeting on 28 July 1992, Sir Terence had indicated that he wished to speak to the issue of de-designation of NICS at the next meeting of the SRSAG, in September 1992. [249]
230 Sir Terence spoke at the meeting, but he does not claim to have mentioned concerns specifically about Bristol. Sir Terence accepted in evidence that he should probably, at least, have set out his concerns about Bristol in writing to Sir Michael. Sir Terence said:
`A. I think that my last meeting of the Group [sic], I certainly spoke to my concerns about the de-designation of the service. I do not think I did mention Bristol specifically at that time. That is where the matter rested. I then left the Group. I know that Professor Browse [President, RCSE, from July 1992] knew of my concerns, but I think he did not feel any need to take them any further forward, and indeed, should not have, unless I had specifically asked him to, and I did not.
`Q. Because he left them with you?
`Q. So it was, as it were, your responsibility?
`Q. And you had expressed them orally to Dr Halliday, but not otherwise?
`Q. And never, it seems, from what you have said, thereafter expressed those concerns?
`Q. Do you think, perhaps, that you ought to have done so?
`A. I think it is a difficult question. I think that I probably should have written at least to the Chairman of the Group, Sir Michael, formally about it, if I had not brought it up to the open meeting, the last one I attended. I suspect that probably is what I should have done.
`Q. Although it may be difficult now in retrospect to say why you did not, can you help as to why you might not have done?
`A. I think I was very cross that the Group had failed to accept the very considered advice of the professional Working Party that they had commissioned. That may have had something to do with it.
`Q. So you felt outwith the Group?
`Q. You simply did not think about raising the issue anywhere else?
`A. No. No. And would not. As I say, I think the right thing probably would have been to have written formally to Sir Michael.' [250]
231 Sir Terence said that after the 29 September meeting (his last as a member of the SRSAG), he felt that the matter was closed and beyond his further intervention. [251]
232 At the end of his evidence, in response to a question from the Chairman, Sir Terence acknowledged that, in retrospect, he should have done more to bring his concerns about Bristol to the attention of others. He said:
`... I do accept the implied criticism, and indeed, the criticism that I should have done more to bring my concerns to the Supra Regional Services Advisory Group specifically about the mortality and the concerns expressed by Dr Zorab, than I did, and in retrospect I think I should have.' [252]
233 The decision of the SRSAG, to designate NICS, stood, coming into effect (taking into account financial implications) in April 1994. [253]
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Footnotes
[236] DOH 0002 0099; minutes of meeting, July 1992
[237] T15 p.78-9 Sir Michael Carlisle
[238] T18 p.168 Sir Terence English
[240] T15 p.42-3 Sir Michael Carlisle
[241] WIT 0049 0034 Dr Halliday
[242] WIT 0049 0034 Dr Halliday
[243] T89 p.170; Dr Halliday explained that Chris Spry, a member of the SRSAG, brokered a funding arrangement with Regional General Managers which lasted until the spring of 1994
[244] RCSE 0002 0197; letter from Professor Hamilton to Sir Terence English dated 3 August 1992 (emphasis in original)
[245] WIT 0031 0006 - 0008 Sir Keith Ross
[248] T15 p.77 Sir Michael Carlisle
[249] RCSE 0002 0200; letters (from Sir Terence to Mr Owen), RCSE 0002 0202 (Mr Owen's reply) and RCSE 0002 0205 (from Sir Terence to Sir Michael); none of these letters made reference to any problems at Bristol
[250] T18 p.174-5 Sir Terence English
[251] T18 p.187 Sir Terence English
[252] T18 p.202 Sir Terence English
[253] DOH 0002 0156; minutes, 29 September 1992