Final Report > Chapter 6: Quality, Standards and Information > Monitoring > The role of the district health authority
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The role of the district health authority
42 Ms Pamela Charlwood, commenting on the approach to judging quality in the period 1984-1995, stated: `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'. [22]
43 Ms Charlwood stated that `from the outset B&WDHA ... tried to concern itself with qualitative issues'. [23] In the early 1980s a number of reviews were held. In 1985 a Performance Assessment Committee (PAC) was formed to monitor the care of patients. The PAC received statistical information from a Medical Information Working Group (MIWG) which consisted of clinicians and managers. [24] Following the January 1989 White Paper `Working for Patients', the MIWG evolved, in 1991, into the District Audit Committee (DAC), by which time the UBH had become the UBHT and service agreements were in place between the UBHT and the District.
44 Miss Deborah Evans, Director of Contract Management, B&DHA, 1991-1995, stated that: `For the first year in which the service agreements ... were in use nationally, 1991-92, Bristol and Weston Health Authority drew up a service agreement ... which included the quality standards that were felt to be appropriate ... This ... included performance monitoring requirements.' [25]
45 During 1991-1995 the DHA was able to monitor some aspects of trusts' performance directly, through a shared clearing-house system which processed data from the computerised Patient Administration System (PAS) of local hospitals. However, the ability to monitor other items of performance and quality was very limited. The systems were not amenable to more in-depth monitoring of such things as rates of mortality and morbidity. [26] The DHA did not have the capacity to monitor all aspects of the quality of the service and relied on each trust to report on selected aspects of quality.
46 The 1991-1992 service agreement between the District and the UBHT for cardiac services (which excluded children under 1) required that the cardiac surgical unit would set up an audit group, part of the function of which was to provide the B&DHA with sufficient information to ensure that adequate audit was taking place. [27]
47 Occasionally, information about mortality rates in the PCS service came to the attention of those within the district and the region, but no particular significance was attached to the figures. For example, in October 1988, when the DHA still directly managed the UBH, the District's PAC considered the mortality rates for PCS for 1987. Members of the committee noted that there were no national performance indicators against which to assess the data. In March 1993 Mr Wisheart presented data for 1992 to the Directors of Public Health network of the South West Region. There is no record of the outcome of the presentation. [28]
48 From the perspective of the B&DHA after 1991, the emphasis in audit was on adult cardiac care, not PCS. Ms Charlwood stated: `Within Bristol there was a consistent interest in auditing aspects of adult cardiac care. The adult service covered large volumes of activity and expenditure and in some cases there were "standards" offered by national organisations - for example, thrombolytic therapy in acute coronary heart disease.' [29]
49 In terms of promoting and encouraging audit activity Ms Charlwood stated that: `From April 1993 onwards, Health Authorities were given a more explicit role in promoting clinical audit and funding audit through allocations and from 1995 through the service agreements.' [30] In 1993 the DHA discussed a joint strategy for clinical audit with the UBHT and other local trusts. An agreement was reached that audit should take place in a small number of areas of shared concern. PCS was not identified by the UBHT or by the DHA as an area of shared concern. [31] Ms Charlwood added that the District's draft specification for adult and children's cardiac services for 1993-1994 included a number of quality standards. One of those standards stated that: `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 of clinical audit.' [32] Ms Charlwood went on, however, that in February 1994: `a report to the B&DHA on quality and effectiveness of care included a paper on clinical audit; "A significant problem was the feeling of clinical professions that clinical practice was not the concern of the purchaser"'. [33] She added: `It was only later in 1995 that decisions to audit pcs openly and mutually arose when the Health Authority learned of the quality issues around the service ...' [34]
50 Dr Trevor Thomas, Chair of the Medical Audit Committee (MAC), UBHT, stated that he was under the impression that the District was receiving mortality statistics for the whole of cardiac surgery. Dr Ian Baker, Consultant in Public Health Medicine, B&DHA since 1991, told us that such data were never received. [35]
51 The B&DHA, therefore, as purchaser, was anxious to receive information on audit and, in particular, the reports (and data on which they were based) of the UBHT's MAC. However, this committee was reluctant to provide this because it was seen as `commercially sensitive' [36] in the context of the new internal market. In fact, the MAC reports were not seen even by the UBHT's Board until October 1995.
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Footnotes
[22] WIT 0038 0022 Ms Charlwood
[23] WIT 0038 0022 Ms Charlwood
[24] WIT 0038 0023 Ms Charlwood
[25] WIT 0159 0027 Miss Evans
[26] WIT 0159 0034 Miss Evans
[27] WIT 0159 0037 Miss Evans
[28] WIT 0038 0040 Ms Charlwood
[29] WIT 0038 0014 Ms Charlwood
[30] WIT 0038 0014 Ms Charlwood
[31] WIT 0038 0015 Ms Charlwood
[32] WIT 0038 0034 Ms Charlwood
[33] WIT 0038 0034 Ms Charlwood
[34] WIT 0038 0015 Ms Charlwood