Annex A > Chapter 8 - Management and Culture of the UBH and the UBHT > The development of the clinical directorate structure > The relationship between academics at the University of Bristol Medical School and the UBHT clinicians
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The relationship between academics at the University of Bristol Medical School and the UBHT clinicians
243 The UBHT is a teaching hospital trust and, as such, has close links with the academic departments of the Medical School at the University of Bristol.
244 Dr Roylance described these links, in some detail, in his statement:
`There has always been an extremely close and intimate relationship with the University of Bristol. All senior NHS medical staff carried honorary recognition as University Professors, lecturers or clinical teachers. All University clinical staff had formal honorary contracts with the District which were then transferred to the Trust on its inception. All appointments committees for senior medical staff included representatives of the University of Bristol and all appointments committees for senior University clinical staff included representatives of the District and subsequently of the Trust. University representatives were appointed to the District Health Authority and to the Trust Board. There were, in addition, innumerable standing and ad hoc committees with representation both of the NHS and the University.
`In particular, there were standing University liaison committees at regional and district level and I was a member for a time of each of these committees. With the creation of the Trust there was created a Joint Committee for Medical and Dental Education and Research with representatives of both University and NHS and chaired by the University Deputy Vice-Chancellor who was a non-Executive Director of the Trust Board. From 1990 there was an increasing relationship with the University of the West of England, at first in relation to management, training and development, and later in the education of nurses and of the professions allied to medicine.
`Together with the Chairman of the Trust I met the Vice Chancellor of the University and the Clinical Dean at least 3 times a year to discuss matters of joint interest. I also instituted a monthly lunchtime meeting, together with the relevant senior managers of the Trust, with the Dean of the Faculty and senior members of the University. All operational matters of immediate joint interest were discussed, particularly those affecting the clinical experience afforded to medical students.' [283]
245 Mr Wisheart encapsulated the view of the UBHT towards the University when he said:
`It was always the view of the Trust that they should work closely with the Faculty of Medicine of the University of Bristol and that they had a lot of common responsibilities, so there were a number of committees and groups which met to try to encourage and nurture and promote that high degree of cooperation.' [284]
246 However, there was a certain tension in that the University would opt to appoint the best academic candidate without regard to the needs of the UBHT to provide the community with a certain service. Dr Roylance explained:
`The university always took the view that they wished to appoint the best applicant and were uneasy about specifying too narrowly the speciality of the potential Professor. So that, if I can explain it out of this, that when a Professor of Gastroenterology retired, ... we finished up with his replacement Professor as an endocrinologist. That always produced a certain amount of stress on the NHS side because we had to continue to provide the gastroenterology and to establish an endocrinology service.
`There were issues, but the University (and quite properly) wanted the best academic and would not normally conform to our wish to narrow the speciality down in the advertisement.' [285]
247 Mr Boardman saw this conflict in needs as both a strength and weakness. He said:
`... I think there is no doubt that having a medical school alongside the hospital adds the enormous strengths; you attract the top people in your field, there is no doubt about that. I think the weakness is that there are times when the core business, the core function of the hospital or the Health Service, has to be to deliver services which meet the local needs of the local population. But at times there is a tension whether the requirements of the University may be to recruit a specialist Professor in a particular field whose discipline could be at the cutting edge of medicine, which is not actually in an area where the local purchasers particularly want or particularly need to buy a particular service.' [286]
248 Dr Thorne was asked what she thought Dr Roylance's emphasis would be if it came to a conflict between the needs of the Trust and those of the University:
`Q. So would it be fair to say that those coming from a university background would have other priorities of research and innovation, and Dr Roylance's was that the focus should be on the patient actually receiving the service?
`A. I think his accent was on actually enabling that tension to co-exist, because he had always seen himself very much as a teacher, was absolutely wedded to the commitment of development and therefore what he wanted to ensure was that unlike a district general hospital, UBHT should be actually at the forefront of changing services and encouraging people to question their practices but not overspend.' [287]
249 Within the remit of cardiac surgery, however, several of the surgeons recognised that there was little relationship between their discipline and the University of Bristol prior to the 1990s. Mr Jonathan Hutter, consultant surgeon, said that:
`... there was no close relationship between the Department of Cardiac Surgery and the University of Bristol prior to about 1990.' [288]
250 Mr Dhasmana recalled that:
`Up to 1992 there was no direct administrative or managerial connection with the University of Bristol ... The academic department of Cardiac Surgery was established in October of 1992 ...' [289]
251 The Bristol Heart Institute, a collection of a number of academic departments of which cardiac surgery was one, was established in 1995 as a new organisation by Professor Gianni Angelini, Professor of Cardiac Surgery, University of Bristol.
252 At a meeting of the cardiac surgeons on 12 October 1995, the Bristol Heart Institute was discussed. The minutes of that meeting recorded:
`The establishment of the Bristol Heart Institute was welcomed as a positive development for the Cardiac Services Directorate. Mr Dhasmana asked for clarification of the role of the clinical service within the Institute. Professor Angelini confirmed that the opportunity was available for the clinical service to be part of the Institute. However, as a formal management structure was not planned, a Management Board would not be identified.' [290]
253 Mrs Ferris, as the author of these minutes, described the atmosphere at the meeting in her oral evidence:
`... these are very innocuous minutes which do not reflect that this was a very difficult meeting and the whole of item 1 about the Bristol Heart Institute represented a very difficult discussion about whether or not the Bristol Heart Institute was valuable to the cardiac services directorate, whether or not the cardiac services directorate could benefit from the Bristol Heart Institute. It focused on how the cardiac services directorate fitted into the Bristol Heart Institute and I know there was some concern from surgeons as to whether almost the Bristol Heart Institute would take over the cardiac services directorate, which is why there is the reference there to the formal management structure. There was the fear expressed that the creation of the Heart Institute would mean the cardiac services directorate would be absorbed into that and there would be a management structure with Professor Angelini as the person in charge of both the academic department of cardiac surgery and the clinical service.' [291]
254 When Mrs Ferris was asked who in particular feared Professor Angelini taking over, she replied:
`I recall Mr Hutter was very concerned about that. I think Mr Dhasmana to a lesser extent, and I think that whilst not sort of openly critical, I know that James Wisheart was very questioning of what this would actually mean. So it was a sort of, if you are looking for a division between surgeons, it was really Mr Bryan, Professor Angelini trying to reassure ... Mr Hutter, Mr Wisheart and Mr Dhasmana that this Bristol Heart Institute was in fact an umbrella for the academic service and would not swamp, absorb or take over the cardiac services directorate.' [292]
255 However, Professor Angelini maintained in evidence that he had no intention of taking over clinical practice. He explained:
`The Bristol Heart Institute was conceived with the approval of the University. In fact, ... the Bristol Heart Institute is a Research Centre within the University, nothing whatsoever to do with the NHS. It has two functions. One is to bring under the same umbrella all the cardiovascular research done in Bristol. This comprises as well as clinicians, biochemists, pharmacologists, physicians and so forth. It has an executive board made of various members, clinical and non-clinical, who meet once or twice a year. The purpose of this is to give strength to any proposal which comes from Bristol, because there is a large body of research groups working in that area. This is particularly relevant nowadays, because, for example, the MRC [Medical Research Council] would not consider any proposal from individual people.
`As a second aspect, I wanted the Bristol Heart Institute to be a separate, if you like, entity in clinical terms and the reason was because I was very concerned as early as the end of 1994, that the performance of the adult cardiac surgery was substandard.
`As a result of this, I did not want to incur the same problems as the paediatric, and somehow I wanted to distance myself from the rest of the Unit. As a demonstration of this, in 1994 and 1995 the Bristol Heart Institute produced an annual report which not only had research achievement, but also clinical results ... It was the first time that institution, the Bristol institution, had produced data which was open to the general public.' [293]
256 Professor Angelini also explained that there are now several such Institutes within the University:
`There is a Neurology Institute. There is now an Institute of Endocrine Neuroscience. These are created by the University. This institute was set up following a request from the then Dean of the Medical School for me to group all the cardiovascular research in Bristol. It was not even my idea in the first instance. There are many other Institutes within the UBHT, but it does not mean they are going to contract us to do the operation. We just have an honorary status with the Trust. We do the operation the same as any other NHS consultants.' [294]
257 The evidence as to the tensions apparent in the setting up of the Institute reflects evidence as to the nature of relationships between staff of various disciplines (and amongst those of the same discipline) engaged in paediatric cardiac surgical services.
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Footnotes
[283] WIT 0108 0013 Dr Roylance
[288] WIT 0096 0038 Mr Hutter
[289] WIT 0084 0046 Mr Dhasmana
[290] UBHT 0229 0005; meeting of cardiac surgeons, 12 October 1995