Final Report > Chapter 14: External Assessment and Monitoring of the Quality of Care in Bristol > The Department of Health

The Department of Health

3 We have set out earlier the role which the Department of Health (DoH) ascribed to itself in relation to the NHS during the period of our Terms of Reference. It was a role in which the factors which were set out and monitored were focused on finance and the volume of patients treated. The quality and performance of clinical services were regarded as matter for the local hospital or health service, not the DoH. Information which was gathered concentrated on performance in relation to the scale of activity in hospitals, and on finance. Waiting times figured prominently. The national database which was built up was intended to be used for planning services, not to monitor clinical performance. This was how the DoH saw its role. As we noted earlier, Sir Alan Langlands, Chief Executive, NHS Executive 1994-2000, described the situation after the establishment of trusts as one which relied on professional self regulation, the development of processes of audit, a rudimentary internal market where purchasers held providers to standards set out in contracts, and a hierarchical relationship between the DoH, health authorities and trusts. All these things would need to be perfectly aligned, he said, to ensure that failure did not occur. [1]

4 Given this context, it is possible now to see that it would have been unusual for a civil servant in the DoH to become directly involved in a particular clinical issue; in our case, in response to the approaches of Dr Bolsin, consultant anaesthetist, UBH/T, about the quality of the paediatric cardiac surgical (PCS) service at the BRI in 1994 and 1995. It is also possible to see how difficult it would have been for anyone in the BRI to know to whom in the DoH they should take matters of concern about a clinical service. Neither Dr Doyle nor Dr Ashwell (both Senior Medical Officers at the DoH), with whom concerns were raised informally by Dr Bolsin, belonged to any system of communication which existed between trusts and the DoH, or between regions and the DoH. Indeed, the main point of contact between the trust and the DoH was the `outpost' [2] which focused principally on financial performance. Dr Doyle was by then (April 1994) the Medical Secretary to the Supra Regional Services Advisory Group (SRSAG), but by 1994 the SRSAG was no longer involved in funding paediatric cardiac surgical services for children under 1. He also had responsibility in the DoH for the development of policy on cardiac services and it was in that capacity that he was in Bristol when Dr Bolsin gave him data in an envelope. When what appeared to be a particular clinical problem to do with PCS services in Bristol was separately brought to the attention of both Dr Doyle and Dr Ashwell, each, in a way, sought to refer it back to the hospital concerned. The prevailing ethos of the time was that such matters should be resolved locally. There seemed to be no alternative means of responding to clinical problems. Dr Ashwell did, in fact, offer Dr Bolsin a vague reference to some forthcoming work of an internal group in the DoH (the Clinical Outcomes Group) which was considering general issues to do with audit. But she was unsure about the role and remit of the Group. For his part, Dr Doyle referred to a quite different Group within the DoH, the Performance Management Directorate, as a possible source of assistance. In short, there was confusion among Departmental officials themselves. The DoH, for historical and structural reasons, was simply unable adequately to respond when an issue of the quality of care was being raised. This is profoundly unsatisfactory. There needs to be a mechanism somewhere to handle such problems. Bristol showed that there was no mechanism, anywhere. The assumption by the DoH was that problems would be dealt with elsewhere. Sadly, this assumption was also the assumption of all the other bodies who might otherwise have been able to act.

5 We conclude, therefore, that the DoH stood back from involvement in the quality of clinical care. It had not created systems to detect or act on problems of clinical care, other than by referring them back to the district or hospital concerned. The focus of the DoH was strategic and not operational. And to the extent that it was concerned with the `operational', its interpretation of what was operational was rooted in matters to do with funding, financial viability and levels of activity. It had systems designed to support these objectives. There were no systems effectively concerned with the adequacy of clinical care. This was a product of the DoH's historical relationship with the NHS, with healthcare professionals, with how the NHS had developed and, latterly, with concerns for cost control. It is not adequate for the future.

Footnotes

[1] T65 p.59 Sir Alan Langlands

[2] The NHS Management Executive established, in 1991, regional outposts to carry out financial monitoring of trusts and to undertake appraisal of strategic capital investment