Witness Name: Professor Sir Brian Jarman

Statement No: First

exhibits:

Dated:

THE MID STAFFORDSHIRE NHS FOUNDATION TRUST INQUIRY

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Witness Statement of Professor Sir Brian Jarman

I, Brian Jarman of Dr Foster Unit, Faculty of Medicine, ImperialCollege, 1st Floor, Jarvis House, 12 Smithfield Street, EC1A 9LAwill say as follows:

Background

  1. I have held hospital posts, including at St Mary’s Hospital, London (now part of Imperial College Healthcare NHS Trust) and the Beth Israel Hospital, Boston (one of the Harvard Medical School hospitals) as a medical resident, and practised as a general practitioner in an entirely NHS inner London practice for 28 years to October 1998, mainly at the Lisson Grove Health Centre. I was appointed as Professor of Primary Health Care at St Mary's Hospital (later Imperial College Faculty of Medicine) in 1984 and later Head of the Division of Primary Care and Populations Health Sciences in the Faculty of Medicine at Imperial College in 1998, where I am now the Director of the Dr Foster Unit within the Department of Primary Care and Public Health.
  1. I have been a member of the Department of Health’s Advisory Committee on Resource Allocation (ACRA) or its predecessors for more than 20 years. I was a Member of the London Strategic Review Panel, set up to advise the Department of Health on the development of hospitals, medical education and research needs of London, which reported in February 1998. I was a member of the Department of Health's Standing Medical Advisory Committee from 1998 – 2005 (when it was disbanded).
  1. From 1999 to 2001 I was a panel member of the Bristol Royal Infirmary Inquiry (the Bristol Inquiry"). Since November 2001 I have worked as a Senior Fellow (now part-time) at the Institute for Healthcare Improvement in Cambridge and Boston, Massachusetts , USA.
  1. I was President of the British Medical Association from 2003 to 2004. I am also a Fellow of the Royal College of Physicians, the Royal College of General Practitioners, the Faculty of Public Health (honorary), the Academy Medical Sciences (Founder Fellow) and ImperialCollege.
  1. Following the Bristol Inquiry, I, with others, founded the Dr Foster Unit at ImperialCollege, London. I attach a copy of my as my Exhibit BJ1 [ ].

Early NHS Background

  1. My first degree was in Natural Sciences at Cambridge, with Physics in my third year. During my second year of National Service I worked on operational research at the Army Operational Research Unit. I then did a diploma in geophysics at ImperialCollege, London followed by a PhD on Fourier analysis of seismic wave propagation. I then worked abroad, mainly in Libya (two years) and the Netherlands, as an exploration geophysicist for Shell. At the age of 31 I left Shell and changed to Medicine, training at St Mary's Hospital, London (now part of Imperial College School of Medicine).
  1. I have worked on the development of socio-economic indicators, mainly the Underprivileged Area score (UPA score or Jarman Index), resource allocation in the NHS, the provision of hospital beds in London, Parkinson's Disease nurse specialists and other projects. I wrote a Social Security benefits computer program (the Lisson Grove Benefits Program) which is now run by two of my ex-researchers and is used in Citizens' Advice Bureaus, Social Services departments, health centres etc. I have acted as an advisor to a number of countries (including Brazil, Gibraltar, Greece, Costa Rica, and Cyprus) on the development of their primary care services. Since about 1990 I have worked on calculating hospital standardised mortality ratios (HSMRs), initially for England, and later for Scotland, the USA, Canada, the Netherlands, Sweden, France, Japan, Singapore, Hong Kong, Australia, Costa Rica and other countries. For about five years I have provided monthly HSMRs for more than 200US hospitals in several hospital systems such as Kaiser Permanente and Memorial Hermann.
  1. I was a member of the Community Health Council in the Bloomsbury area of London from 1974 to 1978. I was elected to the Kensington, Chelsea and Westminster (KCW) Local Medical Committee (LMC) in 1978 and later was one of KCW LMC representatives at the BMA Annual Representative Meetings. As a general practitioner I worked, with hospital colleagues, to facilitate visits by general practitioners to their patients when they had been admitted to hospital. On one occasion I was aware of an adverse event leading to death that I saw when I visited one of my patients in hospital. I believe this was not reported as a Serious Untoward Incident nor used as a learning experience. With my general practice colleagues we started a scheme to enable pre-registration house offices to do four months of their training in general practice as well as in hospital medical and surgical posts in order to promote cooperation between doctors in hospital and in general practice: this is now fairly common (Wilton, J. Preregistration house officers in general practice. BMJ 1995; 310 : 369).
  1. From 1978 to 1983 I was the general practitioner member of Bloomsbury (initially called the North East District of Kensington Chelsea & Westminster Area Health Authority) District Management Team (DMT). After the Griffiths report was published in 1983 I remember the District Administrator member of our DMT saying to me that from then on the managers would run the NHS and the clinicians would be relatively less important.
  1. A 1985 BMJ paper (Norman Ellis. Managing without doctors: realities of Griffiths. Br Med J 1985; 291: 837) stated that "The district management team had two representative clinical members (a consultant and a general practitioner) appointed by their clinical peers, the district medical officer, district nursing officer, district finance officer, and district administrator. Its task was to manage and coordinate the National Health Service's operational services. The district management team provided a structure that enabled consultants and general practitioners to participate directly in management." From my experience, with a nurse, a hospital doctor and a GP on the DMT, it seemed a structure that worked well and one that enabled the clinicians to bring their everyday experience of caring for their patients directly into the management meetings. Griffiths' aim was to: "involve the clinicians more closely in the management process, consistent with clinical freedom for clinical practice. Clinicians must participate fully in decisions about priorities in the use of resources." However, the conclusion of Ellis' BMJ paper was: "To state the obvious, the essence of the health service is clinical care and doctors' daily decisions profoundly affect not just individual patients' lives but collectively the course of the NHS. Furthermore, clinicians will remain the main spenders of its resources. However impressive any district's new management arrangements may seem on paper, its success or failure will depend on whether it achieves its objectives. To attempt to do without the good will and close cooperation of doctors is foolhardy to say the least." When patients are admitted to hospital doctors have the responsibility for the patient's history, examination, investigations, diagnosis, and involvement with medical and surgical treatments. There is evidence that the health service is more effective if doctors work cooperatively in teams with other healthcare professionals.
  1. In the mid 1990s our practice was one of a group of practices that formed the Inner London Multifund, responsible for commissioning NHS services for the patients registered with their practices in inner London. We involved patients, managers, a public health consultant and clinicians in drawing up the contracts for the different services that we put out for providers to bid for. For example, for dermatology, we did 200 patient interviews and 20 focus groups and this made clear what patients required and where there were weaknesses in the current services. Patients, clinicians and managers worked closely together with one aim - that of providing good services for the patients registered with the practices. Our department of general practice researched the model of care and we went with the chair of the Multifund to see the Minister of State at the Department of Health, Alan Milburn, to describe the model.
  1. When I was a member of the Independent Advisory Panel of the 1997 London Strategic Review, chaired by Professor Sir Leslie Turnberg, we suggested, in our report, sent to the Secretary of State, Frank Dobson, on 18 November 1997: "While not being prescriptive, we can commend the pilot locality commissioning projects in which about 60–70 GPs provide and commission services for populations of about 100,000." This concept was proposed in the White Paper "The New NHS – Modern, Dependable", published on 8 December 1997 that led to the formation of Primary Care Groups, which evolved into Primary Care Trusts (PCTs). The White Paper "Equity and Excellence: Liberating the NHS", published in July 2010, had the aim of “Enshrining improvement in healthcare outcomes as the central purpose of the NHS”, with GP Commissioning Consortia commissioning care from providers. This seemed to me to have the potential for involving patients and clinicians in improving healthcare outcomes. However, when I read the draft Health and Social Care Bill published in January 2011 I found relatively few mentions of general practitioners and of patients compared with the White Paper.
  1. In my work with Don Berwick, Maureen Bisognano and others at the Institute for Healthcare Improvement in Cambridge and Boston, Massachusetts, USA I have calculated HSMRs for US hospitals and we have sent them to more that 1000 US hospitals that have requested them. At IHI there has been an emphasis on work related to the quality and safety of healthcare. They use the definition of the healthcare patients require as that which is:
  • Timely: available within a time period consistent with clinical need;
  • Patient centred: the best choice of treatment with the patient sharing in the decision;
  • Effective: provides patient benefit, based on current evidence, avoids overuse and underuse;
  • Safe: conducive to prevention of medical error that often leads to adverse healthcare events;
  • Efficient: without waste;
  • Equitable: same quality of care regardless of race, gender, wealth.
  1. This list was first suggested, nearly as described above, by Robert J Maxwell, Chief Executive of the King's Fund, London in a paper: Maxwell RJ, Quality assessment in health. BMJ, 1984; 288:1470. It was used in a paper by the BMA and National Association of Health Authorities & Trusts (NAHAT) in 1995. It was adopted and modified by the US National Academy of Sciences, Institute of Medicine in the document ‘Crossing the Quality Chasm’, IOM, 2001.
  1. Healthcare quality has been defined as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge"(Lohr KN, Harris-Wehling J. Medicare: a strategy for quality assurance. Quarterly Review Bulletin 1991;17,(1):6-9). Patient safety has been defined in a paper by Linda Emanuel, Don Berwick, Lucian Leape, James Reason, Charles Vincent and others (Agency for Healthcare Research and Quality; August, 2008): "Patient safety is a discipline in the health care sector that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery. Patient safety is also an attribute of health care systems; it minimizes the incidence and impact of, and maximizes recovery from, adverse events."

My experience of analysis of patient data

  1. I first received the English Hospital Episode Statistics (HES) data in 1987/1988 in order to carry our analyses related to the NHS Resource Allocation formula for allocation of resources to NHS hospitals, which my Department at Imperial College were contracted to do, in conjunction with Coopers and Lybrand (as it then was), and Queen Mary College, London by the Department of Health.
  1. I thought it important to investigate the quality of care in hospitals as best I could to see whether this was relevant to resource allocation and I used the HES data to start developing a measure of adjusted hospital mortality, whence HSMRs.
  1. In the mid 1990s I was requested by Sir Graham Hart, Permanent Secretary of the Department of Health, to analyse various factors regarding the London teaching hospitals and wrote a report that was eventually published as: "Jarman B, Astin P, Gault S, Lang H, Ruggles R and Wallace M. 'The contribution of London’s academic medicine to UK’s health and economy' Report for the Deans of the London medical schools. LondonUniversity, London 1997." Part of this study was to compare the Hospital Standardised Mortality Ratios (HSMRs) of inner and outer London hospitals.
  1. I originally had to sign the Official Secrets Act, and have permission from the Secretary of State, regarding the confidentiality and use of the data.

Bristol Inquiry

  1. In October 1998 I was asked by Ian Kennedy to join the four person panel of the public inquiry into children's heart surgery at the Bristol Royal Infirmary 1984 -1995, which he chaired. I was reluctant to spend so much time on the Inquiry (much of it in Bristol) and so I initially declined but eventually agreed in January 1999. My impression was that I was certainly not the first choice of the Department of Health.
  1. The Bristol Inquiry chose a number of statistics experts - the "Inquiry's Experts in statistics, Dr Spiegelhalter, Professor Evans, Dr Aylin and Professor Murray." The Hospital Episode Statistics data were analysed for the Bristol Inquiry at ImperialCollege by some of the people who are now part of the Dr Foster Unit. Dr Aylin is now the Deputy Director of the Dr Foster Unit.
  1. The Bristol Inquiry led me to believe that the Department of Health was the organisation responsible for having systems in place to monitor the quality of care in hospitals.
  1. On Day 99 of the Bristol Inquiry, 9 February 2000 (Final Submissions), page 54, lines 17-24, Mr Pirhani on behalf of the Department of Health stated: “If I may move on, sir, to the area of responsibility and accountability, and make it absolutely clear again that the Department of Health accepts that it is responsible and is accountable for any failings of the systems that were in place during the period covered by the Inquiry. Ultimate responsibility rests with the Department of Health and the Secretary of State.”
  1. However, the Department was clearly unable to respond when an issue of quality of care was raised. Now shown by me at Exhibit BJ2 [ ] is a paper that I submitted to my fellow members of the Bristol Inquiry panel on 8 July 2001 (after modifications of my earlier draft following advice from Mr Brian Langstaff QC, Counsel to the Bristol Inquiry). My conclusions were that the Department: (a) would have been expected to have had a system for monitoring the quality of the care; (b) could have had access to the data necessary to do so; (c) had a mechanism which, although limited, might have been adapted to carry out the monitoring; and (d) had evidence that might have been expected to lead to vigilant monitoring of the Bristol service by 1989.
  1. Two of the administrative mechanisms for monitoring quality of care that the Department of Health had during that era were the Performance Management Directorate and the Clinical Outcomes Group. Part of the roles of these bodies in relation to service quality and clinical outcomes are described below.
  1. The Performance Management Directorate’s charter included the requirement (Bristol Inquiry reference WIT 0482 0219-20, bullet point 2): “To agree challenging objectives with Regions for measurable improvements to health status and outcomes and service quality and efficiency; and to hold the Region’s Chief Executive and Senior Managers to account for achieving them;”
  1. The description of the Clinical Outcomes Group’s role included (Bristol Inquiry reference WIT 0482 0222): “The Clinical Outcomes Group was established to advise the CMO and CNO of the strategic direction of clinical audit and the development of methodologies to identify and achieve improved outcomes and was accountable, through the NHS Executive Board, to Ministers.” The membership included the CMO, CNO (Chief Medical and Nursing Officers) and practising clinicians. It was disbanded in 1997.
  1. Dr Steve Bolsin, an anaesthetist who had anaesthetised during paediatric cardiac surgery operations at Bristol, raised concerns informally with both the relevant Department of Health Senior Medical Officers who had been involved with the Performance Management Directorate and the Clinical outcomes group at the Department of Health. The Bristol Inquiry section on The Department of Health stated that “On 19 July 1994 Dr Peter Doyle, SMO, DoH, attended an audit meeting at the BRI. On his way back to the railway station in a taxi, he was given an envelope which Dr Bolsin told him contained data about PCS [paediatric cardiac surgery]. Dr Doyle told the Inquiry that he did not look at the data. He filed the document.” During the journey Dr Bolsin told Dr Doyle that the envelope “contained data related to Dr Bolsin's concerns.""Dr Peter Doyleinclined to the view that `the clinicians' had the responsibility for monitoring the outcomes of care, as opposed to the SRSAG, but also said subsequently that he had 'no idea' who had the responsibility for monitoring the quality of outcome."The Bristol Inquiry concluded: “The DoH, for historical and structural reasons, was simply unable adequately to respond when an issue of the quality of care was being raised.