Annex A > Chapter 8 - Management and Culture of the UBH and the UBHT > The development of the clinical directorate structure > How did cardiac services fit into the managerial structure?
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How did cardiac services fit into the managerial structure?
118 Initially, from when the directorates were first set up in the run-up to trust status, adult cardiology was part of the Directorate of Medicine, paediatric cardiology was part of the Directorate of Children's Services, and cardiac surgery (including paediatric cardiac open-heart surgery) was part of the Directorate of Surgery. [138] This remained the case until 1993, when the Associate Directorate of Cardiac Services was introduced in a move to structure the care provided in relation to patient groups rather than professional groups. [139]
119 Mr Wisheart explained briefly the management structure surrounding cardiac surgery. He said:
`As far as cardiac surgery was concerned all open-heart surgery, both adult and paediatric, lay within one directorate, initially the Directorate of Surgery and from 1993 the Directorate of Cardiac Services. Cardiac surgery was a sub-directorate within those larger Directorates and as a sub-directorate had its own manager, its own finance and its own facilities. It was run by a Board whose executive members were the associate clinical director, the directorate nurse and the directorate general manager.' [140]
120 Initially Mr Wisheart was the Associate Clinical Director of Cardiac Surgery. In 1993 he relinquished this role as:
`... there [were] issues of workload and there [were] issues as to whether, as Medical Director, I had to make choices or decisions which might have involved cardiac surgery in relation to other directorates. I think it would have been then an invidious position to be in. It is better that cardiac surgery should have a lead and a spokesperson who can speak independently on behalf of cardiac surgery, not fettered by the wider responsibilities.' [141]
121 Mr Wisheart summed up the role of a clinical director as being `to deliver the service, remain in the black and to maintain the quality.' [142]
122 Mr Dhasmana assumed the role of Associate Clinical Director of Cardiac Surgery in January 1993. [143]
123 Closed-heart surgery for children and paediatric cardiology lay within the Directorate of Children's Services which was based in the BRHSC. It had its own management, finance and facilities. However, care of patients took place freely across directorate boundaries, as required by clinical need. [144]
124 Dr Joffe served as Clinical Director of Children's Services from April 1991 to December 1994. This included the Associate Directorate of Paediatric Cardiology.
125 So far as cardiology was concerned, after 1991, Dr Joffe indicated that it:
`... was separated from general paediatrics managerially and became an associate directorate in its own right, within the Directorate of Children's Services. As an associate directorate, the unit attained additional support from one of the assistant general managers. These positions were often held by former senior nurses who were able to bring their clinical experience and understanding into this role.' [145]
`Clinical Directors worked closely, and very successfully, with the general managers (Mr Ian Barrington, in our case) whose role was to oversee the day to day activities of the Directorate and/or hospital. This arrangement promoted greater cohesion and a sense of purpose among the staff at all levels.' [146]
127 As described by Ms Evans, the management of cardiology and cardiac services together was an issue which Avon Health Authority (Avon HA), `regarded as important because it felt that an integrated directorate could have a direct bearing on clinical decision making for certain parents.' [147] `Hospital and Community Health Services in Bristol and District Purchasing Intentions for 1993/94' stated that in respect to Children's Services, `Cardiology and cardiac services will be purchased together as for adults' [148] and `To improve the delivery of service, we intend to stimulate providers to manage these as a unified cardiac service by purchasing them as such.' [149]
128 From 1 April 1994, the Directorate of Cardiac Services came into being. The innovative feature of this new directorate was that it was disease-based rather than professional-based. Professor Vann Jones was the first Clinical Director and Miss Salmon was General Manager. [150] For 12 months previously, adult cardiology and cardiac surgery had been combined as an Associate Directorate of Cardiac Services. [151] In 1994 they came together in a directorate. This led Dr Roylance to explain that the title of Directorate of Cardiac Services was something of a misnomer, since the Directorate was intended only to embrace adult cardiac services. Dr Roylance said:
`... paediatric cardiac surgery was, as soon as we could, moved to the Children's Hospital to a paediatric environment, and a little time before that, adult cardiac surgery was merged managerially with adult cardiology. The Directorate of Cardiac Services, strictly speaking, should have been called the Directorate of Adult Cardiac Services, and was, shall I say, independent of the moves in paediatric services.' [152]
129 Professor Vann Jones explained the difficulties encountered in establishing a disease-based directorate:
`In its initial stages, the Directorate of Cardiac Services was little more than a concept. The paediatric cardiologists were part of the Children's Directorate, the cardiac surgeons part of the Directorate of Surgery, and the adult cardiologists members of the Directorate of Medicine of which, of course, I had just ceased to be Clinical Director. I and my General Manager, Lesley Salmon, had to try to establish what form the new Directorate of Cardiac Services would take, e.g. would it include the cardiac anaesthetists and/or the cardiac radiologists, or would they remain with the Directorates of Anaesthetics and Radiology respectively, etc?' [153]
130 Professor Vann Jones went on:
`My role in these early stages of the Cardiac Services Directorate was to determine who should be in the Directorate so that in due course the appropriate budget could be allocated and the Directorate could then decide its own priorities. Paediatric Cardiology was primarily the responsibility of the Children's Hospital and in any event paediatric cardiology was never envisaged to be part of the Adult Cardiology Service.' [154]
131 Initially, when the Associate Directorate of Cardiac Services had been proposed, a steering group was to be appointed which would consist of a cardiologist, a cardiac surgeon, a cardiac radiologist and a cardiac anaesthetist. This group was to elect its own Chairman to act as Associate Clinical Director. [155]
132 Once the Directorate had been established, Professor Vann Jones established the Cardiac Services Management Board. The individuals who had examined the proposal to form the new Directorate were invited by Professor Vann Jones:
`... to help us in our task of establishing new and effective working relationships within cardiac services.' [156]
133 At the inaugural meeting of this Board, there were cardiac surgeons, anaesthetists, radiologists and cardiologists. The membership:
`... was felt to be correct at present, recognising that it could change if required in the future.' [157]
134 Whilst all of these groups contributed to the Management Board, it does not appear that all were within the Cardiac Services Directorate. Mr Dhasmana said:
`The clinical service in the paediatric cardiac service was provided by medical, nursing and support teams of perfusionists, technicians, physiotherapists, counsellors and social workers at both hospitals. Each of these teams had their own organisational structures and chains of command ... Clinically the chain of command and accountability came under the umbrella of the Associate Directorate of Cardiac Surgery and the Directorate of Cardiac Surgery since 1994.' [158]
135 In 1995 paediatric cardiac surgery was separated from general paediatric surgery and joined with paediatric cardiology to become the Associate Directorate of Cardiac Services in the BRHSC, with the budget re-allocated accordingly. [159]
136 Accordingly, throughout most of the period when there were clinical directorates, until 1995, cardiology, cardiac surgery, and paediatric cardiac surgery had been maintained as distinct entities under different directorates. It was not until 1995 that they were brought together (see Figure 5).
Figure 5: How the paediatric cardiac service fitted into the clinical directorates system
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Footnotes
[140] WIT 0120 0050 Mr Wisheart
[144] WIT 0120 0050 Mr Wisheart
[145] WIT 0097 0139 Dr Joffe
[146] WIT 0097 0142 Dr Joffe
[147] WIT 0159 0022 Ms Evans
[148] WIT 0074 1417 Dr Baker
[149] WIT 0074 1422 Dr Baker
[151] UBHT 0007 0128; Executive Committee meeting minutes, 13 May 1994
[153] WIT 0115 0002 Professor Vann Jones
[154] WIT 0115 0020 Professor Vann Jones
[155] UBHT 0081 0240; Directorate of Surgery paper, 16 March 1993
[156] UBHT 0084 0181; letter from Professor Vann Jones dated 18 October 1993
[157] UBHT 0084 0177; Cardiac Services Management Board minutes, 25 October 1993
[158] WIT 0084 0042 Mr Dhasmana
[159] WIT 0097 0139 Dr Joffe