Final Report > Chapter 14: External Assessment and Monitoring of the Quality of Care in Bristol > The Supra Regional Services Advisory Group
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The Supra Regional Services Advisory Group
6 Established as a funding mechanism, the SRSAG gathered data on the number of operations performed, but this was with a view to fixing funding levels for future years. While information on the performance of units (in the form of mortality rates) reached the SRSAG, it did not see its role as being to assess or monitor clinical performance.
7 Thus, when Dr Halliday, Medical Secretary, SRSAG told the Inquiry that he was `without the machinery to analyse' [3] data on mortality, his comment goes to the wider point, that the SRSAG did not see itself as having a role in this respect. The difficulty is that while this may have been obvious to the SRSAG, it was bewildering to others. Confusing impressions arose and were given. The SRSAG certainly requested data on mortality from supra regional centres (SRCs). By so doing it gave the impression that mortality rates had some bearing on its decision-making. Indeed, it may well have given the impression that it was monitoring performance and was in a position to do something about performance if there were concerns. The lack of clarity about the SRSAG's role was compounded when, in 1991, the SRSAG began to act as a `purchaser' mimicking the emerging relationships between DHAs and trusts. Annual service agreements (contracts) were established between the units providing neonatal and infant cardiac surgery (NICS) and the SRSAG. These included references to quality, but the expectation in the service agreement was that it was a matter for individual units, not the SRSAG, to ensure that the service was satisfactory from a clinical point of view. [4]
8 The picture is made more obscure by the discussions [5] which the SRSAG had in 1992 concerning the possible de-designation of the whole of NICS because of the proliferation of units carrying out such work. One option considered was to de-designate particular units, based on the low volume of open-heart operations carried out. Bristol was one of the two units describes as being `at risk'. After discussion, it was agreed by the SRSAG that designation of all the units should continue. One reason given was that `it would be difficult if not invidious to de-designate the centres in question on the basis of surgical expertise'. [6] This is an important observation. If it means that the SRSAG had data demonstrating that the surgeons in Bristol were obtaining good results which were comparable to those obtained by others, so that choosing between them was invidious, it means that the SRSAG was monitoring performance and the quality of care (and was mistaken since the data did not support such a view of Bristol's performance). But, as we have seen, Dr Halliday consistently stated that this was not part of the SRSAG's role. There could be another meaning: that the SRSAG did not wish to make hard choices concerning designation which might offend the clinicians concerned. But the SRSAG was there to make hard choices. The proper care of patients demanded it, whether or not clinicians and colleagues were offended.
9 The role played by the SRSAG seems to have been, therefore, to concentrate on its primary task of safeguarding and nurturing financially vulnerable services. Monitoring volume was part of this task in the case of NICS. But the quality of care provided was seen as something for others to assess and monitor.
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Footnotes
[4] The service agreement between the SRSAG and the UBHT, for example, provided that the unit: `will ensure that the quality of services will be clinically and socially satisfactory, and will seek constantly to improve it.' The BRI was to monitor regularly: `all relevant aspects of the service, and make the results available to the purchaser'. It was also the unit which was to provide an annual report dealing with such matters as `quality of service' and `statistics', as well as information on waiting lists and copies of the agreement on quality reached with the major purchasers (see DOH 0004 0004)
[5] DOH 0002 0044
[6] DOH 0002 0044