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

The District Health Authority [8]

12 Until the creation of the Bristol & District Health Authority (B&DHA) in 1991, the relevant district had since 1982 been the Bristol & Weston District Heath Authority (B&WDHA). Ms Charlwood, Regional General Manager, SWRHA (1993-1994), Chief Executive, Avon Health Commission and Avon Health Authority (since 1994), provided us with a full and helpful account of the District's activities in the area of monitoring standards of quality. [9] She stated that from the outset `B&WDHA appears to have tried to concern itself with qualitative issues.' But she made it clear that the criteria for judging quality changed over time to reflect changes in the Government's priorities. More importantly, she stated that `The criteria chosen, and their indicators, were mostly of a general nature and on a large scale, so did not draw attention to concerns about surgical outcomes in a particular specialty at a particular hospital.' Moreover, `... much of the ... information did not differentiate paediatric from other cardiac surgery.'

13 In 1985 a Performance Assessment Committee (PAC) was set up by B&WDHA `to monitor patient care', but it was noted that: `... no separate routinely available information is recorded for the outcomes of neo-natal care in relation to neo-natal surgery both cardiac and non-cardiac.' Paediatric cardiac surgery was not one of the services reviewed by the PAC in 1986. In 1987 a sub-committee of the PAC, together with Dr Roylance as District General Manager, set up a review of the Central Unit (BRI and BRHSC). PCS was not identified as a concern. In September 1988 the PAC received a report from its Medical Information Working Group (MIWG) concerning cardiothoracic surgery. The report noted the lack of comparative figures in the form of performance indicators. It was also minuted that Mr Wisheart referred to the `national register of cardiac cases'. This appears to have been taken as an indication that some external form of monitoring was taking place in the case of PCS. The PAC received the 1987 Annual Report on the PCS services. [10] Ms Charlwood noted that `Mortality rates in the Report were described as virtually identical to those obtained nationally as published in the UK cardiac surgical register ... but the Minute ... says "Members ... noted that there were no national performance indicators".' [11]

14 Ms Charlwood concluded that up to that point the B&WDHA had:

`... recognised the need to monitor performance in terms of outcomes for patients; acknowledged the impracticability of assessing all outcomes in specialities [sic]; opted to monitor specific services each year; ... [and had] not seen or heard anything about paediatric cardiac surgery to warrant selecting it for scrutiny.' [12]

15 The B&DHA took an interest in the quality of care provided by the UBHT, from the moment that it was set up in 1991 in succession to the B&WDHA. In 1991 it set out provisions relating to the quality of care in the service agreement with the UBHT. The agreement also anticipated that units within the UBHT, including the PCS service, would set up an audit group. But a distinction was made, at least on the part of the UBHT, between reporting to the B&DHA that a mechanism for audit was in place, and informing the District of the actual audit information. The latter was not forthcoming. Thus, although the service agreement contemplated that there be an audit of outcome, including measures of 30 day mortality, one year morbidity and one year symptomatic state, the District did not obtain this information. [13] It could not, therefore, monitor the quality of care provided.

16 Over time, purchasers increasingly sought to set standards of quality and to obtain audit information from trusts, but there remained a gap between aspiration and reality. In the B&DHA's draft specification for Adult and Children's Cardiac Services for 1993/94, the District listed amongst standards of quality: `the quality of investigations and interventions will keep case fatality and morbidity to the minimal levels according to National Standards and will be the subject of monitoring and clinical audit'. [14] This may be described as a valiant effort, particularly since there were no accepted national standards on levels of mortality and morbidity. Quite whether and how the District monitored the service is not clear. In early 1994 a B&DHA paper on clinical audit stated: `A significant problem was the feeling of clinical professions that clinical practice was not the concern of the purchaser'. [15]

17 We conclude therefore that the District, between 1991 and 1995, sought to use the tool available to it, the service agreement, to get some grip on monitoring and securing the quality of clinical care. The agreement's lack of legal force, the continued reluctance of healthcare professionals to release audit information and the fact that information was considered a commercial confidence meant that the District's efforts were frustrated. Another element in the system, with the best will in the world, was not up to the task.

Footnotes

[8] Bristol & Weston District Health Authority was established on 1 April 1982. Bristol & District Health Authority formally came into existence 1 October 1991 and remained until 1 April 1996

[9] WIT 0038 0022 Ms Charlwood

[10] `Annual Report on Paediatric Cardiology and Cardiac Surgery at the Bristol Royal Hospital for Sick Children and the Bristol Royal Infirmary, 1987'. See Annex A Chapter 19

[11] WIT 0038 0023 Ms Charlwood

[12] WIT 0038 0023 Ms Charlwood

[13] See T62 p.115 Dr Thomas and WIT 0108 0019 Dr Roylance

[14] WIT 0038 0034 Ms Charlwood

[15] WIT 0038 0034 Ms Charlwood