Annex A > Chapter 7 - Supra Regional Services > Monitoring of quality
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Monitoring of quality
234 Dr Ian Baker, Consultant in Public Health Medicine, B&DHA since October 1991, took the view that although he had a responsibility to ensure that the service for the over-1s was producing an acceptable outcome, the supra regional service for the under-1s was `supervised through their [i.e. the SRSAG's] own arrangements'. [254]
235 Those involved in the SRSAG itself did not share this view. Mr Angilley, Administrative Secretary of the SRSAG, said:
`The statutory responsibility for the provision of health care and therefore for standards is firmly in the hands of the local health bodies that provide that service.` [255]
236 Dr Peter Doyle [256] inclined to the view that `the clinicians' had the responsibility for monitoring the outcomes of care, [257] as opposed to the SRSAG, but also said subsequently that he had `no idea' who had the responsibility for monitoring the quality of outcome. [258]
237 The question as to what, if any, responsibility was accepted by the DoH for the designation and performance of an SRC, and to what extent it took the view that it had, as direct paymaster, control over such units was dealt with by a number of witnesses.
238 Sir Alan Langlands, Chief Executive of the NHS Executive, [259] placed responsibility on the local hospital, subsequently the Trust:
`In the case of NHS Trusts, Supra-Regional funds were allocated directly from the Department of Health to the NHS Trust responsible for the Supra-Regional Unit with effect from 1 April 1991. The NHS Trust took on managerial and clinical responsibilities for the proper use of those funds.' [260]
239 As to Districts, Sir Alan saw them as having had no real responsibility for SRSs:
`There is, or was at that time, a clear responsibility on district health authorities to ensure that the health and health service needs of their population were being adequately met and that means the whole range of services from primary to tertiary services. But beyond that, I can see that there is no real responsibility here and that the responsibility is much easier to define in relation to individual clinicians, the Trust where that service was located and the NHS Executive who, through these advisory groups, were running the national commissioning arrangements and allocating money.' [261]
240 Nonetheless, the evidence was that responsibility for the quality (in the sense of clinical outcome) of SRSs was confused. This confusion was considered by Sir Alan to be a failure for which the NHSME was to some extent responsible. In response to a question from Professor Jarman, he stated:
`... there was confusion and ... the distinctive roles and responsibilities of each of the players was not adequately clarified. I think that the Department of Health, the NHS Executive in particular, must take some responsibility for that. It falls into my category of systemic failure. You cannot expect people to behave sensibly in this position unless they are absolutely clear where they fit in. So I think the position is as described, I think there was a failure there, a confusion.
`Q. Just to take that further, that may be related to the fact, as Sir Graham Hart said to us, that the NHS had no proper measurement of the quality of care it was providing. I just wonder whether you feel that the reason for confusion you mention and the lack of proper measurement that he mentioned could have been related to the fact that, as he said, ministers were unwilling to get involved in dealing with the profession, the medical profession particularly, with regard to matters of clinical performance?
`A. I think I would separate the points. I hold up my hand to the fact that there was confusion here. There is no denying it. The fact that I have not been able to adequately explain it today or cover it effectively in my statement suggests that there was confusion. I think that is wrong. I think that I and the NHS Executive should take responsibility for that. I could mount all sorts of things in mitigation about how busy everybody was at the time and what a terribly complex change it was, but I do not. I think it is wrong that these roles and responsibilities were not clarified. On the subject of proper measurement, I am conscious of the fact that this is an area you know more about than I do, but I think there is a separate point there, which is that services like this all around the globe are trying to find effective forms of measurement. I think we are towards it in the data sets, the audit processes that I described earlier in relation to cardiac surgery. So I would want to separate the two points.
`A. On the third point about the attitude of Ministers, well, again, I think it depends on timing. I can never remember a situation where Ministers said "We are reluctant to get involved in the clinical processes". But I do remember a culture where it would have been unusual for Ministers to get involved in the detail of clinical activity, but equally, in this period of the early 1990s, there were some very dramatic cases, for example in relation to mentally ill people where Ministers did intervene and did want to see very fast improvements in service and did require the NHS Management Executive, as it then was, to behave in a managerial way. I would think that position is now more pronounced and that current Ministers have no hesitation about intervening in areas where they feel, rightly in my view, responsible and where they feel they have to act, so that the actions they have taken in reinstating the very important quality assurance arrangements in relation to the breast and cervical screening services I think was an absolutely justifiable intervention, which no clinician in their right mind could have suggested was inappropriate. So I think attitudes have been changing over time, and I think that really the point I want to get across here is a sort of evolutionary point: that through all of this, the relationship between the government medical profession and the public has been changing and I think Sir Donald Irvine brought this out very well in some of his evidence, which suggests that issues of public accountability and self-regulation have to be in keeping with the current public mood. They cannot somehow be rooted in the past or in sort of romantic notions of clinical freedom in a bygone age. We are living in a different world.' [262]
241 That there was confusion and uncertainty as to responsibility for the monitoring of clinical outcomes in the SRSs, with a view to ensuring appropriate quality of care, was endorsed by a number of other witnesses. Professor Crompton expected the SRSAG to do it:
`I would have expected from the beginning, when they established the supra regional centres, that there would have been a system of data capture and analysis and publication from each of the centres, distributed freely to the Department of Health and to Regional Health Authorities who were sending patients there from Wales or wherever and that the Supra Regional Services Advisory Group would have been in full knowledge of all the facts relating to this important initiative. If that was not the case, then I am surprised.' [263]
242 The SRSAG supervisory mechanisms were described by Mr Angilley in his statement:
`As Secretary to the Advisory Group, my work included the monitoring of activity levels and costs at the designated centres against the Group's expectation when it agreed levels of funding. In the early years we carried out no detailed monitoring of cost and activity through the year and relied on annual figures submitted by the designated centres. These figures showed actual and forecast levels of activity and cost. The Advisory Group used this information to produce recommendations on funding of each centre in the following financial year. My background as an economist led me during my period in post to seek improvements in the costing and activity statistics provided by the centres. The introduction of contracts in 1991 was accompanied by quarterly activity figures as well as an annual report from the unit. The contract set out the format of the annual and quarterly reports.' [264]
243 As to performance in SRCs, the SRSAG looked to the Medical Secretary to raise any issues and the Medical Secretary, in turn, looked to the College members on the SRSAG to comment on performance.
244 The Colleges could visit or, if requested, report but they did not initiate reviews. It was not until 1991 that there was a suggestion that the Colleges should `police' the system. [265]
245 However, Sir Terence English told the Inquiry:
`I do not believe that the Royal College of Surgeons or Physicians, or any other Medical Royal College, can be held responsible for performance in individual units. I think the value of the Colleges resides in their capacity to provide professional advice when invited, and to do so in as objective and fair a way as possible. I think if there are difficulties that crop up in a unit, a College or two Colleges can combine to provide a visitation that can be quite extensive, and then very helpful to management. I think the Supra Regional Services Advisory Group had a responsibility - a difficult responsibility, but a responsibility nonetheless - for performance in the units that they designated, because they were funding them.' [266]
246 Dr Halliday made clear in his evidence that the SRS was a funding arrangement, and that the SRSAG did not have responsibility for monitoring the quality of the care provided by supra regional units:
`I was the architect of the Supra Regional Service arrangements. It was I who drafted all the papers, made all the proposals and negotiated with the profession. At no time did we consider that the Advisory Group which would eventually be set up would have monitoring responsibilities for any of the services. Their role was to advise the Secretary of State on which services would be centrally funded. It was a funding arrangement.' [267]
`... the statutory duty for provision of health services rests with the Health Authorities... The Supra Regional Services Advisory Group did not alter the statutory arrangements.' [268]
247 Dr Halliday saw the local hospital management as having the role of monitoring quality, prior to the 1991 reforms. During the first occasion on which he gave oral evidence, he said:
`None of the supra regional services functioned in isolation. They were almost invariably part of a general hospital. So the management of the general hospital would have to manage the unit which was designated supra regional. I would have expected them to look after the provision of facilities and all outcome measures that they would want to use in any sphere, as they would with any other service.' [269]
248 The evidence of Professor Sir Kenneth Calman, Chief Medical Officer for England (CMO) from 1991-1998, was that:
`A. I considered that it would be the responsibility of the Supra Regional Services Advisory Group to ensure that there was a process for monitoring; and that that process and the outcome was reported to the Supra Regional Services Advisory Group.
`Q. It is not quite exactly what you said before.
`A. I am trying to clarify it for you.
`Q. Before you said they would be responsible for monitoring it, they could go upwards to the Department of Health or go to specialists.
`A. They were responsible for ensuring the system was in place for monitoring the outcome. They could not do the monitoring themselves. They would get the data once it had been monitored and if there was a problem, presumably they would talk to an appropriate person within the Department of Health.
`Q. So they were responsible for getting a system and looking at the results?
`A. I think in general, that is the Department of Health's responsibility: ensuring that there are systems in place which monitor the data. They do not necessarily monitor it themselves. So I am sorry if I have confused you. I do not think I have confused myself on this, because I think they did have a responsibility to ensure that it was being monitored, and that the results would be fed into them.
`Q. So when you say "they" it is the Department of Health and the SRSAG, working together, [which] had the responsibility for making sure there was a system and looking at the results to see if there was a problem?
`A. Yes.' [270]
249 Sir Kenneth was asked about the same topic by the Inquiry Chairman:
`Q. ... was it your evidence that there ought to be a system for monitoring as well as a system for seeking advice, or was it your evidence that the SRSAG itself should do the monitoring?
`A. I do not think the SRSAG itself could do the monitoring, because it would not be set up to do that, but it should be ensuring that there was a system in place to do the monitoring.
`Q. And looking at the results?
`A. I think looking at the results too.
`Q. And examining the results?
`A. Yes.' [271]
250 When this evidence was put to Dr Halliday (when he gave oral evidence for the second time, in December 1999), he agreed that the SRSAG had a responsibility for ensuring a system was in place for monitoring outcomes, but only in the latter part of the period, after the introduction of contracting in 1991:
`Audit was not a major interest of the Department of Health at the time. Myself, I kept it as a policy issue within my division all the time that I headed the division, which was for 15 years.
`Each year I was constantly told that medical audit was not part of the Department's responsibility and that I should drop it, and I argued that I should retain it as long as I met all my other targets in terms of work. As long as pursuing that activity did not affect my other work I should be allowed to retain it, and I did.
`So we were very active in encouraging medical audit in the field, despite the fact that it was not Departmental policy at the time.' [272]
251 Dr Halliday emphasised that the SRSAG was dependent on the `medical profession for any data which it had as to surgical outcomes and surgical performance ...' [273]
252 Sir Michael Carlisle stated that the SRSAG was not `a rubber stamp committee'. However, he too emphasised the degree of reliance that the SRSAG placed on senior members of the medical profession for interpretation of data and `early warnings' about problems with the service. Sir Michael's evidence included this exchange:
`Q. What you are perhaps telling us, and again, correct me if I am wrong, is that if it occurred to you that there might be serious grounds for concern with any particular unit, leave aside one doing neonatal cardiac infant surgery, that your first port of call would have been to the medical men to say, "Well, look, give me a view on this. What is this all about?"
`A. Absolutely right. One relied upon them, I suppose in a manner of exception reporting, to come forward if there were known perceived problems in any unit where they had knowledge and expertise. We had a substantial network formally and informally for medical people. I have referred to the President of the Royal College of Surgeons; there were other eminent medical people on that group, and I think there was a sufficiently powerful group of people and network of people to be able to pick up evidence, albeit verbally, of problems.
`In those cases, those had been brought or raised at the committee, at the [SRSAG], I would have seen action was taken to do something about enquiring more about it.
`Q. So you, in wishing to take things forward in the best interests of patients, as you did, you were really reliant upon the input that the medical men had to give you?
`A. Absolutely so. It is not my area of expertise to interpret medical data.' [274]
253 With effect from 1991 service level agreements, described as `contracts', were entered into for the delivery of SRSs. Sir Michael accepted that, `as a contractor, the Department of Health obviously had an accountability [for the way in which SRSs were managed].' [275]
254 On a final matter concerning performance and monitoring, Dr Halliday was asked how often it was that a supra regional unit was de-designated on the grounds of poor clinical performance. He was unable to recollect an example of this:
`We have de-designated services, but I cannot recollect us ever de-designating a particular unit. It is very difficult to de-designate units, because although you might find that the profession supported the decision, there might be a reluctance, you know, a decision to de-designate the service, there might be a reluctance to de-designate a particular unit. There are often very good reasons for that. For example, Guy's was a unit that was constantly being referred to as one that should be de-designated, but it is very difficult, when you go along to see the unit and you find in fact they are leading the world in prenatal diagnosis, they are one of the leading international units in interventional catheterisation, and say, "De-designate this unit". It is very difficult'. [276]
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Footnotes
[256] The Medical Secretary of the National Specialist Commissioning Advisory Group (successor to the SRSAG) since 1994
[259] Sir Alan Langlands was Deputy Chief Executive of the NHS Executive 1993-1994, and thereafter became Chief Executive
[260] WIT 0335 0044 Sir Alan Langlands
[261] T65 p.64-5 Sir Alan Langlands
[262] T65 p.103-6 Sir Alan Langlands
[263] T21 p.72 Professor Crompton
[264] WIT 0034 0002 - 0003 Mr Angilley
[265] SCS 0004 0032; minutes of meeting, 21 February 1992
[266] T18 p.200-1 Sir Terence English
[270] T66 p.98-9 Professor Sir Kenneth Calman
[271] T66 p.100-1 Professor Sir Kenneth Calman
[274] T15 p.29-30 Sir Michael Carlisle