Final Report > Chapter 12: Responses to Concerns and Actions Taken, and Whether Such Actions were Appropriate and Prompt > Responses outside the UBH/T > The Supra Regional Services Advisory Group
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The Supra Regional Services Advisory Group
3 We accept that, although there was only a qualified endorsement of PCS at Bristol in 1984, the arguments in favour of designation were defensible. These were the need for coverage in the South West, and the potential for development in Bristol, provided that the service was supported and monitored. But, as time passed and the results, both in terms of throughput and outcome, failed to improve, we would have expected a greater degree of vigilance in considering the progress made and the options for the future. One of these options would have been to discontinue support by de-designating the service in Bristol. While we accept that this, of itself, would not necessarily have brought PCS to an end in Bristol, since the SRSAG had no power to prevent PCS being undertaken, we take the view that such a step would have attracted sufficient attention to cause the service to be evaluated carefully before being supported further by the UBH/T.
4 The 1989 report commissioned by the SRSAG from the Society of Cardiothoracic Surgeons of Great Britain and Ireland (SCS) (discussed at the SRSAG's July 1989 meeting) included information about poor outcomes in Bristol. While not in itself sufficient to require immediate action, this information might have been expected to lead to vigilant monitoring of the service in Bristol by the SRSAG, through which it was funded. Dr Halliday visited Bristol in 1990, and sub-optimal results were noted. But these were attributed to the low volume of work. Whether accurately or not, increasing volume was at the time widely held to be associated with improving results. [1] Thus, to look for higher volumes as a way of achieving better outcomes was not unreasonable. But the focus on throughput may with hindsight be thought to have distracted attention from further inquiry, as the Bristol results, with the exception of the figures for 1990, showed no real improvement as regards outcomes in PCS on the under-1s. The final events leading to de-designation of the service in 1992 reveal a lack of effective communication between expert advisors, DoH officials and the Chair of the SRSAG. It is regrettable that, in the light of evidence in existence over time (up to 1992) Sir Terence English, President of the RCSE and member of the SRSAG, holding the position he did as a leading cardiac surgeon, did not advise the SRSAG that he was concerned about the poor outcomes of the Bristol Unit and that they deserved investigation or action. We acknowledge that he drew these matters to the attention of Professor David Hamilton, Chair of the RCSE Working Party, and it is common ground that he mentioned that he had reservations about Bristol to Dr Halliday, but regrettably he did not inform members of the SRSAG and particularly the Chair, Sir Michael Carlisle, of the nature of his concerns. We add that we were particularly impressed by the frankness with which Sir Terence gave his evidence and by his willingness to admit to error or misjudgment in this regard.
5 It is important to remember, however, that, at this time, responsibility for monitoring the quality of care of PCS in the under-1s, in the sense of reviewing the outcomes, had no clear place in the system, whether locally in Bristol or centrally in the DoH. Dr Halliday did receive some mortality data from Bristol but said that he did not have the `machinery to analyse it'. [2] Professor Farndon told us there was no effective system for monitoring the quality of care in PCS in Bristol. Sir Alan Langlands told us that the DoH had a responsibility for setting up a system for monitoring matters such as finance and volume of cases, but that quality of care was a matter for the employer. The Royal Colleges regarded the task as one for the employer, or the DoH. Others regarded it as the duty of the individual doctor to ensure the quality of care. Equally, audit for a large part of the time covered by the Inquiry's Terms of Reference was an educational tool rather than a device for ensuring quality. Measures described at the time as indicators of quality were still predominantly concerned with indirect clinical aspects of care, such as waiting times. The choice of topics to be audited remained with clinicians. Moreover, audit did not take place across the boundaries between specialties, making it even more difficult to get a clear picture of a complex, multi-specialty team activity like PCS.
6 In short, there was no effective national system for monitoring outcomes. This situation was compounded by the assumption by a number of the respective organisations that it was not their responsibility but that of some other body. This meant, in turn, that the absence of, and need for, a national system was not recognised nor acknowledged at the time.
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Footnotes
[1] T7 p.75-6 Dr Michael Godman. (We note that the Joint Working Party of the Royal College of Physicians and the Royal College of Surgeons of England in 1987, DOH 0002 0223, had noted the link between low numbers of patients treated and higher mortality, and that Bristol had low numbers of cases)