Annex A > Chapter 7 - Supra Regional Services > Monitoring of quality > The inability to control `proliferation'
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The inability to control `proliferation'
284 Sir Michael Carlisle emphasised that the powers of the SRSAG were limited:
`But to get back to your question, we have no directional powers. Much is made of "designation" or "de-designation", but I do not feel we were doing anything else but trying to get the profession to control the proliferation of this service, and others, voluntarily.' [316]
285 The question was put to Sir Graham Hart, Permanent Secretary at the DoH from 1992 to 1997, whether the Secretary of State for Health could take steps to limit proliferation. Sir Graham said:
`My understanding is that ... some of the units that were doing these procedures outside the supra regional services arrangements had a good record. So why should he [the Secretary of State], in a sense, intervene? I think he created the right kind of environment in which the tendency would be towards limitation and specialisation, but he was not, as it were, putting down an absolutely rigid framework within which there was no room for movement at all.' [317]
286 In supplementary written evidence to the Inquiry dated 9 February 2000, Sir Terence said:
`... the "profession" never had the power to rationalise the service. All we could do was to provide authoritative reports on what we felt was best for the service, in the belief that if we recommended de-designation of units in order to preserve the continued designation of the whole service, this would be acted upon by the SRSAG and the Department of Health. Being centrally funded services gave the SRSAG the power to cut off funding for units, which may not have made them stop immediately but which would have been a big disincentive to carry on the work.' [318]
287 In a supplementary written statement to the Inquiry dated 18 December 1999, [319] Dr Halliday made the point that control of proliferation was all the more difficult in the NHS after the reforms of 1991, since trusts had more freedom to decide which services they would provide and, at least in the early post-reform years, competition was encouraged.
288 Dr Halliday accepted that:
`In the interest of patients and the service generally all the evidence points to the need to concentrate the services in as few units as possible.' [320]
`Managers in non-designated units who allow such services to be provided, must be held responsible. If funding was not provided, the clinicians could not undertake the work.' [321]
289 In his supplementary statement, Dr Halliday also accepted that the DoH, the Welsh Office and the Royal Colleges were not able to influence the referral pattern to the Bristol Unit. [322]
290 Dr Halliday accepted that the supra regional arrangements themselves were not sufficient to bring about the degree of control over the development of the service which would be needed to keep down the number of centres undertaking NICS. [323] He was asked:
`Q. ... If we go back to your statement, 49/3, the second sentence of your paragraph 3, you dealt with one reason for setting up Supra Regional Services Advisory Group arrangements and you say: "Another equally important reason was to control the development of such specialised services." Have I misunderstood what you meant by that?
`A. You have not misunderstood, but the arrangements themselves were not sufficient. I mean, clinical medicine is not something that is easy to control, as we see from every country in the world, so that a system like this required additional powers from other sources before they could actually impose control.' [324]
291 At the end of the first session of Dr Halliday's evidence, the Chairman questioned him about the difficulties of the supra regional provision of NICS:
`Q. ... The impression I have is that as a service - let alone we are talking about any particular unit - this particular service concerned with neonatal and infant cardiac surgery, etc., was doomed from the start, in that the very criterion of one year had an element of arbitrariness in it. The criteria for supra regional services could not appear to ever be met, at least in some of the units. There were either going to be too many units or there was not enough throughput; there was already an existing and established service; there was therefore an inability to make dirigisme from the centre actually work. There were no financial sticks, only carrots. And there was always the issue of clinical freedom, whatever that may mean, operating against the interests. Would that be a fair set of observations, or have I got it completely wrong?
`A. No, that is entirely fair, but the other element of that is the situation where the Department was aware that there were allegations by reputable, experienced clinicians that there were children who were not being diagnosed and treated in this speciality. You cannot ignore that.
`We were aware that there were parts of the country in which we were very poorly covered, and other parts of the country which were over-generously provided, so there had to be something done about the service. The supra regional service advisory arrangements appeared to offer that mechanism, and it has worked in other services very effectively.
`We then consulted with appropriate Colleges and their view was that it should be a designated service. In fact, their view is to this day that it should be a designated service, but I agree with you, it has not worked. But we did try.
`I think that is all one would expect a Department to do: to try to make the system work. If it is not possible for a variety of reasons, and there are no powers to ensure that it happens, then there is nothing we can do.' [325]
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Footnotes
[316] T15 p.57 Sir Michael Carlisle
[317] T52 p.25 Sir Graham Hart
[318] WIT 0071 0067 Sir Terence English
[319] WIT 0049 0034 Dr Halliday
[320] WIT 0049 0019 Dr Halliday
[321] WIT 0049 0019 Dr Halliday
[322] WIT 0049 0016 Dr Halliday