Annex A > Chapter 7 - Supra Regional Services > Monitoring of quality > The encouragement/strengthening of the Bristol Unit
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The encouragement/strengthening of the Bristol Unit
273 Dr Halliday placed some emphasis on the fact that the Royal Colleges inspected the supra regional units regularly. [303] He was not able to be specific as to the content of the strengthening steps which might have been expected from the Colleges.
274 Dr Halliday was questioned by Mrs Maclean of the Inquiry Panel on the nature of support for Bristol from the Colleges:
`Q. ... You suggested that you were looking to the Royal Colleges for support in the development of Bristol. I wonder if you could give me some examples of the kinds of things you meant by that support?
`A. Actually, I did not say I was looking to the Royal College for support, I said that the Royal College had offered their support. You see, the Colleges are responsible - one point perhaps I should have made earlier is that we are very fortunate in the way that our Royal Colleges assist us, because they are not formally part of the National Health Service. They have no responsibility for the provision of services. Their role is educational and the training of doctors. Yet despite that, they are only too happy to contribute their time, and sometimes money, to look at the things we want them to address. So I think we are very lucky in that sense.
`In the case of Bristol, we were in a situation where the Advisory Group had decided, based on all the evidence we had, that we should designate the neonatal and infant cardiac surgery. If we did not have a centre in the South West, a significant part of the population would not be served. We had to take into account Wales as well, although Wales was not part of the supra regional service arrangements.
`When it was suggested that Bristol be designated, even then we had concerns, because it did not seem to be, you know, as good as the other units in terms of facilities, staffing and so on. When the College offered, through Sir Terence, to say that they would assist us in strengthening that unit, my interpretation of that would be that the College had "powers", in inverted commas, through their visits to say whether the facilities were effective, and if they were not effective, they could withdraw their recognition of it being a training post. That is a very powerful weapon for managers.
`The second thing is that they can influence their young consultants coming along, or Senior Registrars, and suggest to them that if they would like to apply to Bristol, it would be in their long-term interests. So I expected them, both in terms of their visitations and encouraging staff, good staff, to take posts in Bristol, that they would strengthen the unit.
`But it is not something I could actually interfere with. The College has its own way of ensuring its standards are met.' [304]
275 Sir Terence rejected the view that the SAC or the Hospital Recognition Committee (HRC) was better placed than the SRSAG to gather intelligence on NICS. He told the Inquiry:
`As far as neonatal and infant cardiac surgery is concerned, the College would become informed and involved at whatever time they were asked to look at a particular problem or to do a particular piece of work for the Group, but otherwise the detailed information that we would gather from the five-yearly visit of the SAC and the five-yearly visit of the HRC to a particular designated unit, that information, although strong on training, in terms of the total service, would be less than I would have expected the Supra Regional Services Advisory Group to have held themselves, because they designated these units and they had the purse strings and they were monitoring them.' [305]
Sir Terence was asked about the extent to which the SAC for cardiothoracic surgery had regard to the `quality' of surgery performed by the consultants providing the higher training in the specialty:
`A. I think this was approached variably by different members of the SAC, different visitors. Some would enquire informally into it, others would like to see the results from the previous few years. We had ours available at visits with mortality statistics against them; others did not. It was not a requirement as such. It was perhaps something - well, it certainly did not receive as much attention as the quality of the training which the individual was receiving.
`Q. Quality of training was the whole purpose of the visit?
`Q. So inevitably, quality of outcome would not, could not, receive as much consideration as that, but I think what you are telling me - I want to be sure I am right about it - is that whether formally or informally, it was the expectation of all concerned that those visiting the unit would ask about quality of outcome, or quality of surgery?
`A. I think the reality of it was that generally, throughout surgery, it was not regarded - it was not common to enquire specifically about mortality at SAC visits. I am not sure about that, but as a generalisation, I think that is true.' [306]
276 Sir Terence explained that to the extent that the SAC visits looked at `quality' they did so by reference to factors other than the surgical results of the consultants:
`They would be primarily interested in what the facilities were in that hospital: the number of operating sessions that were staffed and available for training; the number of times that the Registrar could attend an outpatient clinic, ward rounds with consultants, how many times he or she was operating on their own or with consultant help, or assisting consultants. They had a logbook which was introduced in the late 1980s, I think, which all trainees, when they were registered with the SAC, had from then on to keep, and it was an account of every operation that they were involved with, either as the first operator or as the assistant, and they were required to keep information on mortality in that.
`That would always be discussed at the time of the visit. But that was looking at the trainee's operative outcome in terms of mortality rather than his boss's, or the unit's.' [307]
277 Visits by the HRC and the SAC to the same hospital at about the same time could produce different pictures of the institution inspected, as was the case at Bristol in 1994. [308]
278 Sir Terence told the Inquiry that, by 1986, when he chaired an RCSE and RCP Working Party [309] looking at NICS:
`... it was apparent that Bristol had not developed to the extent that we may have expected; that there was a problem with respect to the development at that time. It had certainly not increased its numbers hugely. But it was felt that there was still the potential there and that it would be worth reviewing it and seeing how it went in the next few years.' [310]
279 The 1986 Working Party concluded that on the basis of current and future likely demands for NICS, it was not possible to justify more than nine centres for England and Wales. Indeed, on the grounds of cost-benefit considerations alone, the view was that it might be advantageous to concentrate the work in as few as six larger centres. Sir Terence agreed that this conclusion would have meant that smaller centres such as Bristol, Newcastle and Guy's would have been vulnerable to de-designation. [311]
280 Sir Terence told the Inquiry that the Working Party intended the SRSAG and the local hospital management in Bristol to do the `encouraging' of Bristol:
`Q. Were you there suggesting that the Supra Regional Services Advisory Group itself should do the encouraging?
`A. Yes, and more generally than that: that one would hope that it would have filtered down from there to the hospital itself, to the management of the hospital and to the staff involved in that hospital; that a report like that, which would inevitably go to the supra regional units themselves, one would hope, that they would take account of it.
`Q. The encouragement that was to be given: what form did you think that would take?
`A. I think all sorts of ways: the provision of the facilities, if this was the block, appointment of an additional surgeon or anaesthetist skilled in paediatric anaesthesia - wherever the block lay, it ought to be corrected.' [312]
281 Sir Terence said that he did not think that there was anything that the Royal Colleges could do other than to draw attention to the need to `encourage' Bristol:
`I do not think that there was any specific encouragement which either the Royal College of Physicians or the Royal College of Surgeons could have given to the BRI at that time to increase their throughput in paediatric neonatal and infant cardiac surgery.' [313]
`... this was a service which had been designated by the Advisory Group [SRSAG]. They had asked an opinion in the Colleges as to what the present situation was; they were given that opinion, but controlling the purse strings, as I have already said, really gave the Department a huge potential for some control over development. I can only suspect that that was not exercised in this particular case where it perhaps should have been.' [314]
283 Sir Terence explained that he saw the role of the Royal Colleges as being essentially reactive, setting up committees and producing reports when requested to do so by the SRSAG. He said:
`... I would put it to you that the Colleges have the responsibility of providing a professional report on a particular service or a particular issue when asked by the Supra Regional Services Advisory Group, who, on the basis of that report, ought to then require the local hospital to improve that service, because they are funding it.' [315]
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Footnotes
[305] T17 p.37 Sir Terence English
[306] T17 p.26-7 Sir Terence English
[307] T17 p.28-9 Sir Terence English
[308] Compare the SAC visit of 8 July 1994 (RCSE 0002 0222) with the HRC visit of 13 July 1994 (RCSE 0002 0234). See, generally, T17 p.39-56. Within the Royal College of Surgeons, Sir Terence told the Inquiry that, in essence, any cross-referencing between two such Reports would be more a matter of accident than design; see also T17 p.57-8
[309] RCSE 0002 0009; RCP `Working Party Report'; note that Professor Hamilton was also a member of this Working Party
[310] T17 p.87 Sir Terence English
[311] T17 p.90 Sir Terence English
[312] T17 p.95 Sir Terence English
[313] T17 p.99 Sir Terence English