Annex A > Chapter 9 - The Split Service > Comments by those involved in management and finance on the split site
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Comments by those involved in management and finance on the split site
122 Avon HA pointed out in its written evidence to the Inquiry that:
`The Bristol and District area was not alone in having in-patient children's care provided from a number of hospital sites. This was the case in many cities including those which had children's hospitals which were separate from other district general hospital provision, and the location of which did not always fit with the development of specialties such as renal services, cardiac services, neurosciences and plastic surgery.' [123]
123 Avon HA stated that in 1983 the Bristol and Western District Health Authority (B&WDHA) had received advice from the Management Advisory Service of the NHS. The B&WDHA's Planning Group undertook a series of consultations and the Division of Children's Services `argued strongly for programmes towards centralisation of children's inpatient services on the BCH site'. [124]
124 Avon HA stated that after a further review of acute and related services by B&WDHA's Policy Planning and Resources Committee:
`... at a meeting on 31st October 1986, the representatives of the Division of Children's Services continued to press for integration of children's services'. [125]
125 On 16 October 1990 Dr Baker wrote to Miss Deborah Evans, Contracts and Quality Manager, B&WDHA:
`... paediatric cardiologists were anxious for the new "contract" to contain "some expression" of the need for children to receive cardiac surgery in a children's department. This was accordingly expressed in the 1991/1992 service agreement between the B&WDHA and the UBHT.' [126]
126 In July 1993 B&DHA began a:
`... "strategic review" of selected services for its residents ... One of the key elements of change highlighted was to identify 15 hospital specialties that might benefit from some consolidation, including general paediatric surgery'. [127]
127 Avon HA stated that this proposal for a review was influenced by the paper `Towards the Millennium: Specialist Services for Children in Bristol', issued in February 1993. [128] The paper recommended, amongst other things: `... a move towards a single children's inpatient service in Bristol'. [129]
`The Authority developed and undertook an intensive programme of involvement with advisors up to the Autumn 1994. Six service area working groups were established, one looking at Acute Hospital Services ... In the Acute group, six particular services were examined, including specialist children's services.' [130]
129 In its advice, dated 9 June 1994, the Bristol & District Paediatric Committee:
`... explicitly advocated that where children's services had developed alongside their adult counterparts, they should meet a nationally-recommended standard for children's care and that could be achieved only by "realignment from organ-centred to age-centred patient care''.' [131]
130 In her written evidence to the Inquiry, Miss Deborah Evans indicated that the management of cardiology and cardiac services as a single unit was regarded as an important issue for the Avon HA `because it felt that an integrated directorate could have a direct bearing on clinical decision making for certain patients'. [132]
`In 1993/1994 and thereafter Bristol and District Health Authority issued a single specification for children's cardiac services (i.e. cardiology and cardiac surgery combined) and another single specification for adult cardiac services (cardiology and cardiac surgery combined).' [133]
132 Dr Pitman, consultant in public health medicine at the South Western Regional Health Authority/South and West Regional Health Authority (SWRHA/S&WRHA) from 1980 to 1996, in her written evidence to the Inquiry stated that, in March 1984, the SWRHA was considering how to deal with the proposed expansion of cardiology. She referred to a draft report:
`At the present time, patients' lives are constantly being placed at risk by the need to transfer very young children between the Bristol Children's Hospital and Bristol Royal Infirmary every time a catheter investigation is needed.' [134]
The report proposed that the catheterisation rooms at the BRI and the BRHSC be re-equipped.
133 Dr Roylance told the Inquiry that he was aware, in 1985, of some views favouring a move of paediatric cardiac surgery to the BRHSC but:
`That was not a universally supported view. [135] There were still those who thought that the expertise in cardiac surgery lay at the BRI and that it might be better to import paediatric expertise into the BRI. But I was aware and by 1987, I think by then, I think it was by then or soon after, more neonates were being operated on than before which precipitated the problem and made it clearer to everyone that it would be better if the neonates were in a paediatric unit.
`So I knew, at that time, and we tried from that time, James Wisheart in particular, with my enthusiastic support, to try and find a means of achieving that desired aim, so that around 1987, I think there was no longer an argument that it would be preferable for children to be nursed in a children's hospital, at that time ... So the desire was there. The achievement was much more challenging.' [136]
134 Dr Roylance explained how this was achieved:
`We engineered a situation, a very welcome situation, whereby, to achieve the latest increase in adult cardiac surgery, we either had to build more adult cardiac facilities at the BRI or build children's facilities at the Children's Hospital, so creating space for the adult surgery.' [137]
135 Dr Roylance went on, in the following exchange:
`A. ... we found a solution in the 1990s.
`Q. But the solution was one which really depended on funding?
`Q. Had there been a source of funding available to move the children's cases from the Royal Infirmary to the Children's Hospital earlier than the 1990s, would you have taken advantage of it?
`A. Yes, but if there were funds available for that move, we would have spent it on that move.' [138]
136 Dr Roylance was asked by Counsel to the Inquiry whether he was aware that, from 1987 to 1988, capital was potentially available (depending on the application being accepted) for the development of SRS:
`... sources of funding were usually brought to my attention. I cannot tell you now whether it was. I will say that the Advisory Group recommended that priority be given to applications relating to services where significant workload expansion was expected, and I suspect that that was the reason why this was not a pathway which could be trodden.
`You see, we were relying on a significant workload expansion in adult cardiac surgery. What we had been saying and what we were talking about, a significant workload expansion was not expected, as I understand it, in 1987 and 1988.
`I cannot be certain, all I can use is my experience and these documents, and what is implied is that in order to get capital for expansion, one had to demonstrate a realistic expectation of that expansion. We were looking for money for translocation, not expansion.' [139]
137 In a letter of 31 January 1992 Arthur Wilson, Deputy Regional General Manager at the SWRHA, wrote to Dr Roylance concerning capital funding: [140]
`I am writing to invite you to produce a proposal for cardiac services that takes into account: a) increased capacity b) unification of children's services and c) steps to meet quality and cost concerns of purchasers.'
Mr Wilson's letter sought the proposals by 9 March 1992 for consideration by the RHA.
138 Dr Roylance described his understanding of the development of paediatric cardiac surgery:
`When paediatric cardiac surgery was started, it was considered that the essential expertise that was needed to be concentrated was that of cardiac surgery and they were performed right across the country by surgeons, cardiac surgeons, who performed operations on adults and children.
`In other specialties, that is still the case, but as more and more neonates were operated upon, it became increasingly apparent that a paediatric facility was more important than a cardiac surgical facility. Therefore, 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.' [141]
`As I understand it - I think paediatricians may put a more extreme view - it was about creating a better environment in which care could take place; it was not about the success of that care. I mean, we were by no means the only unit which had a split site between paediatric cardiology and paediatric cardiac surgery. Because of the way the specialty developed, that is the case in a number of other units, I cannot tell you which ones, but I do know that that is not a unique situation by any means.' [142]
140 Dr Roylance was asked by Counsel to the Inquiry about the views of Mr Elliott, in the following exchange:
`Q. Did you know that Mr Elliott had expressed the views that I have revealed in this line of questioning, that there was, as he saw it, disadvantage in the split site to the point of potential danger?
`A. Yes, but not to the point of danger. As I have already explained to you, I did not actually see the paper written by Martin Elliott until after the appointment of Gianni Angelini, or some time around there, but he did not say it was dangerous, he said there was the potential for danger. I clearly read that in a different way from what you are suggesting. Quite clearly, I do.
`Q. If it were suggested to you, then, revisiting my earlier question, that the service or part of the service was a potential danger to patients in a particular respect, is that something that you - as a manager unable to reach a clinical view because you were not a clinician in that particular service - would nonetheless wish to take advice upon?
`A. If the gist of the advice I was given throughout was that a situation was undesirable but in no way unacceptable, then I would regret the undesirability and attempt to correct it.
`If anybody had suggested to me that they were describing a situation that was unacceptable, then I have told you what I would do about it. Just at the top there [indicating screen], I do not know what it refers to, "was totally unacceptable to me", not "totally unacceptable". The tone of this and the implication was that he supported our view that consolidation of the service on one site was highly desirable. He at no stage says, "and you should not be providing the service the way you are". It is not said. I think if he thought we should not have been providing the service in the way that we were, he would have told me. He would have told somebody, not just the person providing the service.
`Q. The last question, perhaps, before we have our afternoon break: a situation in which a service may be potentially dangerous, or is potentially dangerous: is that acceptable or unacceptable, would you say?
`A. It depends what the words mean. The words as I understand them, it means acceptable but undesirable. You are putting to me that [it] is different. I do not believe anybody who believes that a service is dangerous and should be stopped would ever leave that ambiguity.' [143]
141 Mr Nix, in his written evidence to the Inquiry, stated that throughout the 1980s the B&WDHA had collaborated with the SWRHA in efforts to finance the expansion of cardiac surgical services. The SWRHA had set up a number of working parties in the early 1980s which made recommendations relating to the expansion of the service and for funding requirements for both capital and revenue. [144]
142 The Report of the Strategic Planning Working Party, presented to the SWRHA in March 1984, addressed a number of options for the increased provision of adult/paediatric cardiology. The preferred option was to provide a biplane cineangiograph machine [145] because:
`3.6.4i Avoids the high risk of transporting critically ill infants between BCH and BRI.
`3.6.4ii Maintains ready access to expert Paediatric support - Neonatal, Anaesthetic, Intensive Care, Nursing, etc.
`3.6.6iv This arrangement would avoid the current situation where the investigation of many urgent paediatric cases has to be deferred until the end of the routine sessions.
`3.6.7 This option is the only one that enables the appropriate developments to be made in both Adult and Paediatric fields without compromising the clinical needs in either area.' [146]
143 Mr Nix stated that an assessment of the costs of transferring paediatric open-heart surgery to the BRHSC was undertaken in the late 1980s:
`... not only was affordability an issue at the time but there was also concern about the availability of trained medical and perfusion staff to cover the two sites'. [147]
He stated that further assessment was undertaken in the early 1990s as part of a review of the need to expand the capacity for adult cardiac surgery.
144 Mr Nix indicated that other capital projects and developments were competing for scarce resources. He set out some of the major developments which took place throughout the 1980s and 1990s:
- `Expansion of cardiac surgery from 275 cases to around 1, 100 cases per annum
- `Building of the new Bristol Eye Hospital
- `Building of the Avon Orthopaedic Hospital
- `Replacing several of the linear accelerators used for the treatment of cancer
- `New general hospital at Weston Super Mare
- `Transfer of learning disability patients into small family homes in the community
- `Building four new operating theatres at the BRI
- `Developing a Bone Marrow Transplant unit for Children now dealing with about 80 cases a year
- `Transferring the beds for the elderly from Manor park to the BGH [Bristol General Hospital], closer to where the patients live.' [148]
`A further review of service provision in 1993/94 identified a financially viable plan to move paediatric open-heart surgery to the Children's Hospital. This plan was to be financed by the purchasers providing greater funding for an expanded adult cardiac surgery service. Because of the overall size of the expansion in adult surgical services required, the possibility of transferring children's surgery to the Children's Hospital was investigated and found to be affordable. ... Funding for the capital investment was found from the Trust's capital, NHS Executive Regional Office capital and from charitable sources. Development work at the BRHSC started in late 1994 and finished in November 1995.' [149]
146 Mr Nix told the Inquiry that cardiologists, paediatric and adult alike, had been arguing for paediatric open-heart surgery to be moved to the BRHSC for some time by the start of the 1990s. [150]
147 Mr Nix was asked by Counsel to the Inquiry about an application for funding led by Dr Joffe, made in 1992:
`Well, up until Friday evening last week, I was not aware that we had made a submission. There were no papers in any of my files related to this yet you had mentioned something to me and I spoke to Kate Orchard, the Manager of Cardiac, and she said she was asked about it at the GMC, and on Friday I spoke to Mr Wisheart and asked did he know anything about it and on Friday evening I saw a copy of a paper that had been submitted in 1992. In fact I saw two papers. The first was one that I had written which was what work would need to be undertaken to make a submission and that was dated the 9 June, and then, about a fortnight later, the very short paper had been submitted. It was sent down under a compliments slip from Dr Joffe and on that compliment slip it indicated that Mr Owen had suggested that the application should be made and that an application that had been sent in was an interim statement. I do not recall being involved.' [151]
148 Mr Nix agreed that opportunities were available for applications to be made for capital funding to the Supra Regional Services Advisory Group (SRSAG) in the late 1980s: `... clearly there were'. [152]
149 Asked whether the need to increase capacity in the BRI to meet the demand for adult cardiac surgery was the reason why paediatric cardiac surgery moved to the BRHSC, Mr Nix said:
`Yes, and it brought with it, because of the demands from purchasers and the need that was shown in our waiting lists and the number of emergencies, that finance was available to cope with both the cost of the capital investment and the ongoing revenue cost of running the service at the Children's and at the Royal Infirmary.' [153]
150 Mr Nix told the Inquiry that the concerns expressed by Dr Jordan in his paper of 7 December 1990 were addressed in the mid-1990s because they were allied to the need to increase the capacity for adult cardiac surgery. [154]
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Footnotes
[123] WIT 0074 1778 Avon HA
[124] WIT 0074 1777 Avon HA
[125] WIT 0074 1778 Avon HA
[126] WIT 0074 1778 Avon HA
[127] WIT 0074 1779 Avon HA
[128] WIT 0074 0160 Avon HA; there appears to be an earlier draft of this document dated September 1992 at HAA 0081 0056
[129] WIT 0074 1779 Avon HA
[130] WIT 0074 1779 Avon HA
[131] WIT 0074 1779 Avon HA
[132] WIT 0159 0022 Ms Evans
[133] WIT 0159 0022 Ms Evans
[134] WIT 0317 0005 Dr Pitman and HAA 0095 0029
[135] The Inquiry did not hear a single voice raised against it
[136] T24 p.109-10 Dr Roylance
[139] T24 p.112-13 Dr Roylance
[140] UBHT 0038 0411; letter dated 31/1/91 but received 9/2/92 therefore should have been dated 31/1/92
[143] T88 p.114-15 Dr Roylance
[144] WIT 0106 0040 Mr Nix
[145] This is an X-ray machine for recording angiography on cine film, and the recordings are done in two planes simultaneously
[147] WIT 0106 0042 - 0043 Mr Nix
[148] WIT 0106 0043 - 0044 Mr Nix
[149] WIT 0106 0044 Mr Nix