Richard Langton Hewer talks to Hugh Ross

HR OK, well I think we will see the redevelopment of the Bristol Health Care facilities both hospitals and community facilities, as a long-term plan 10 years probably, maybe 12 years. I have been asked to lead the team for the first 3 years on secondment from UBHT and I am now putting together a small team to help me do that. At the moment the team consists of, apart from Maria Fox, my secretary here, just 3 other part-time secondments from North Bristol Trust (NBT) and UBHT to help with planning, public involvement and document writing itself.

HR No. One is a communications and information person, one is a project management person and one is a planning person and they are all people who have been involved in major capital schemes and major capital planning for a number of years and aspects of it. So that is the size of the team at the moment, but obviously if we are successful in our public consultation and we do get agreement from the Government to have the major investment that we need, then I would envisage the team being much bigger over time. The teams of people who are running the major PFI projects for example in other parts of the country are anything up to 25 or 30 people such is the scale of the exercise.

HR Small team to start with but obviously if things go well we shall grow over time.

HR The remit is to pull everything together. I think you have observed Richard as have other people, that there has been a lot of disconnected planning in Bristol in the past and I dont think the old Health Authority quite frankly necessarily had the grip on strategic planning that was required. As a result UBHT developed its own plans really because it was felt that it was so urgent that something be done and North Bristol started developing its own plans because it felt that its situation wasnt going to be tenable as it was. Then of course, understandably, the Powers that be above said, to the Health Authority, you must have a strategic back-cloth to put all this against and hence the whole review was then pulled together. My job is to pull together several strands of work. One is the plans that the UBHT and NBT have been working on. Another is the Lift scheme to invest and develop in community care premises and also to pull together the work that is being done on Diagnostic and Treatment Centres across Bristol, North Somerset and South Gloucester. So it is really putting it all under one umbrella, trying to make sure it is co-ordinated, trying to make sure the community developments are informed by and inform developments in the hospitals and that we present to the public a coherent whole picture of a health system redevelopment, not a piecemeal bit here and a piecemeal bit there. Thats the remit. Hence the programme, the whole programme is called The Bristol Health Service Plan to emphasise it covers all aspects of health care delivered in the area, not just hospitals and not just community facilities.

HR No indeed.

HR Yes. I have only been in Bristol for 7 years, so inevitably all my knowledge is not first-hand. You are right about the hospital stock. I mean we have a hospital that was built as a prison in the Napoleonic Wars, we have

HR Blackberry Hill. We have prefabricated huts from the Second World War, we have two that were built as work-houses, we have the old building at the Bristol Royal Infirmary dated 1735. I mean you are right, it is a shocking collection really. Why did it come about? Well, what happened I think in the great hospital building programme of the 70s and the 80s was that there were some developments in Bristol but most of the energy in this part of the world was focused on arranging new hospitals up and down the M5 and the M4, some of which are only coming to fruition now, but some of which have been built for quite a few years. I am thinking of developments in Plymouth, Torbay, Exeter, Swindon, Gloucester and Taunton. The Regional Centre really, as happened in other Regions, was sort of left behind. That should have been put right by some concerted strategic planning in the 1980s and early 1990s which should have led to the first new hospitals opening now, or the refurbished hospitals opening now.

What happened as far as I can tell and the echoes of this if you like were still around when I came to Bristol in 1995, was the Health Authority did launch a strategic plan in 1993 and 1994 but it didnt have the support of any of the three Trusts who all attacked it to some degree and it contained some proposals that nowadays we would think very sensible, like a better centralisation of Childrens services, making sure that we handled major trauma better, those sort of things, which of course will be part of the plans that we put in front of the public in the near future, but because they didnt, for whatever reason, get the support of the Trusts, these proposals were attacked on all sides, both by Trust management and by hospital doctors. They didnt find favour with some general practitioners, they certainly didnt find favour with the public. As a result, strategic planning in Avon kind of ground to a halt and it wasnt until UBHT and then North Bristol started preparing their own plans that the system was sufficiently stimulated to say "hang on we have got to organise this better". So that would be my "take" on it. Other people would have their own views, but that would be my view on it.

RLH Yes, thank you.

HR Why that happened I think quite frankly was neglect of that issue from the people who should have been doing it.

HR Well it has put us in a very parlous position and you are right, we are some years behind the other major centres.

HR Well we will be 10 or 15 years away from the final new facilities being available but I think as we hope to do things in stages, we will have a lot of new facilities available bit by bit as the years go on, but you are right, the whole programme, that is the sort of time it takes.

RLH Those stages have to fit in with an overall strategic plan.

HR They do, and of course they have to be affordable.

HR We are still hoping to start in early January running through to nearly up to Easter I guess.

HR Well, in its simplest sense, it will be the issue of a consultation document and a wide circulation of information about what we think the options are for future health care systems in Bristol and what we think we should do. Of course, that would be supported by a lot of meetings, road shows, media campaigns, interviews with lots of leading clinical staff from around the City, and meetings with counsellors and the scrutiny commission of the Council and indeed any way we can in order to try and get across to people what the choices are. The decision about which options we put in front of the public, as far as the hospital is concerned, will be made by the Boards, the local NHS Boards, on the 18^th and 19^th November, thats the plan at the moment. But in making those decisions, they will have been party to many of the discussions with people like representatives from local councils, the Community Health Council, the universities, i.e. the other important statutory stakeholders if you like, and public representatives, so that they will have every chance to hear the debate, but the actual decision about on what we should consult, will be made by the local health boards.

HR No, it is the Primary Care Trusts and the Trusts. So it is the hospital Trusts including Weston, because this is about services for North Somerset as well, it is the Ambulance Trust and the Mental Health Trust and it is the 5 Primary Care Trusts, two in Bristol, one in South Gloucestershire, one in Bath and North East Somerset and one in North Somerset. So all those bodies have an important stake; and then that decision to go to consultation has to be ratified by the Health Authority because it is actually Avon, Gloucestershire and Wiltshire which is the body with the statutory responsibility to decide on consultation.

HR Thats right. They have to approve whether we consult or not, as does the Minister of Health.

HR Oh yes. There is a reference group for the whole of the programme which contains all the Chairs and Chief Executives of all these bodies and that meets every month and around the table with the Chairs and Chief Executives are people like lead GPs and local councillors.

HR Well it is a big body. It is about 30-35 people. The universities are represented, the Community Health Councils and so on. This is the steering group if you like, although this is the wrong term to use, because there are actually a Chief Executive Steering Group, but that is the overall group that guides the programme and basically makes the key decisions about which options go forward and which dont.

HR There is some suggestion certainly they should be more organised as a clinical network and that is in tune with Government policy. Similarly with childrens services now, the Chief Executives, in fact something I did before I left UBHT, the Chief Executives had delete sort of agreed to set in hand a review led by Tim Chambers supported by Ian Barrington, from the Childrens Hospital, to look at a more formal clinical network for Childrens Services, to try and make sure they are better planned and better delivered for the future, and of course that goes across into local authorities and all sorts of other things, as you well know.

RLH Yes, I spoke to Tim Chambers.

HR And we have to make sure that whatever capital redevelopment we do, that we have a much more joined-up service in the future than we have in the past, so although my emphasis will be on the rebuilding programme and the refurbishment and the redevelopment programme, hand in hand with that has to be new ways of working. New ways of making sure that barriers between organisations do not get in the way of patients, things like that.

HR There has been some integration and less duplication of services in this City. For example cervical cytology was centralised onto the Southmead site 2 or 3 years ago now, but that was as much as a result of Government policy on that issue as opposed to anything else. There have been a number of small service changes arising that did actually come out of the last strategic review, although some of them took many years to bring about. An example would be the centralising of the rheumatology in-patient services at Southmead Hospital.

HR The in-patient service has been, yes. And another example would be the centralising of the in-patient neurology service at Frenchay and another example would be the centralising of the specialist haematology services in the BHOC The Bristol Haematology and Oncology Centre, so some small aggregations, some small rationalisations, have taken place, which I am sure have all led to better patient care, but they have been relatively small shifts and we are still, probably by the standards of some cities, still trying to do too many different things in too many different places. Certainly some other major centres have tackled these issues, perhaps more vigorously than Bristol has, for a variety of reasons.

HR I think it is. I mean we are all very clear. I think certainly the hospital doctors are very clear and I think they are absolutely right that whatever we do do in the City with the reconfiguration of hospitals, we must aim more and more for single clinical teams working across the City as the way forward rather than, you know, struggling to meet difficult rotas on different sites and so on. So however many hospital sites in the long-term I think we need to change the way we work.

HR Yes. This is raised all the time Richard. I think it is a bit of a red herring personally. It is worth saying that the Regional Director has made it quite clear that as far as she is concerned, mergers are a tremendous consumer of time and energy and resources and very unsettling and she would cite you a whole range of examples. I have heard people in North Bristol tell me that it probably lost the two Trusts a couple of years of momentum when Southmead and Frenchay merged and it has been a long and difficult process.

When I came to Bristol, one of the first things I did was suggest that the three Trusts, as it then was, co-operated on about 16 or 17 areas. One of the Chief Executives, who shall remain nameless, from the North, refused and said no I dont think that is appropriate. Ever since then I have worked away in my UBHT role to try and get better working across the City and I have to say things are much better now. Firstly, with John Hill Tout, being the Acting Chief Executive North, and then since Tony Woogar took over, you will find that a lot of work is going forward. Occupational health services have been merged, run as one, the Internal Audit Departments are run as one, supplies procurement is now run as one, there is talk of integration and a network of pathology and so on - so we are on our way! I think providing the two Trusts continue working ever more closely together, you can get where you need to get without the fact that they are separate Trusts being a problem, as long as they are all signed up to the same long-term plan. I think if the fact that they were separate organisations got in the way of what needs to be done, then you would have to review the position, but I think the loss of momentum and the loss of focus and concentration would be absolutely enormous, but certainly at the moment, as I say, the line from above is it is not on the agenda.

I know people will continue to talk about it but the line from above is you are two big Trusts anyway. If you put them together, it would be the biggest in the UK. That would raise lots of issues of manageability and so on and frankly getting there would be enormously difficult. We have an awful lot to get on with such as the enormous financial deficit in Bristol, meeting the Government targets, sorting out the long-term plan, and getting a five hundred million pound investment programme going. The message from above is get on with it and I am telling you that is the way it is.

HR I think it will. The time may come when the two Trusts are working so closely together everybody says well this is a natural thing that can be done very easily, but at the moment it will be I think desperately time consuming and difficult.

HR Oh absolutely, and it is working much better than it was even a couple of years ago, I am glad to say.

HR That was the original objective.

HR Well the Labour government abandoned that didnt they when they came in in 1997, saying that competition was not the way forward. They are now seeking to reintroduce some limited competition based on price tariffs in order to introduce a degree of contestability, I think is the word in the market, although it is not really a market anyway, but introduce a degree of contestability as opposed to competition. What the outcome of that policy decision is, which of course has not been implemented yet, remains to be seen, but I would be personally very disappointed if it has turned back the clock to the days of Trusts being more competitive against each other because I think we have seen where that led us and quite frankly, it may have led to some improvements in efficiency and things like that, but it certainly didnt lead to the kind of joined-up service planning that we are now trying to do. In fact it worked against it if anything. So I would be very concerned

RLH The question now would be, surely it would be a disaster?.

HR If we lost the growing cohesion that we now have and certainly the Strategic Health Authority and Mark Outhwaite, the Chief Executive there, makes it abundantly clear that he expects the health community to work as one and to work together to sort out its problems and he will have no truck with people trying to declare UDI and doing their own thing and I think the fact that he is so certain about that, is very helpful.

HR I think that is fair. One of the unfortunate features of the current performance management system for the NHS is that it is very vertical it doesnt really take account of health communities. It looks vertically down the scope if you like at individual NHS bodies and you are quite right, if you have a series of targets set for individual Trusts, and quite frankly the success or failure of the Trust and its senior managers, is seen very much in the terms of its performance against a few very limited objectives, then not unreasonably that Trust will focus on meeting those objectives and will not necessarily help out a colleague who is in trouble and that is a problem. I think that is changing. Mark Outhwaite again has made it clear that the star rating as a Trust will depend just as much on how you collaborate and work to the common good as how you perform against the various scores.

HR No, I think it is changing because the Government has realised that the current system does produce some potentially perverse incentives. What we need to do of course is to find a way of measuring the performance of the whole health system and how people cooperate and work with each other as well as getting some information on the individual organisations which have statutory responsibilities in their own right. These are large public bodies and obviously must be performance-managed if the tax payer is going to be assured that they are doing a proper job, because between them the MBT and UBHT spend over five hundred million pounds a years of tax payers money. A vast sum of money. Many relatively large corporations are very small in comparison. Well known household names are tiny by comparison with the sort of money that the NHS spend locally so you must have proper performance-management. But you are right, that potential perverse incentive is there, but bit by bit we are maturing beyond that. I think the Government needs to make the performance-management system more broad-based, more mature and they are doing that of course, they have tried to change it, they have tried to bring in clinical quality issues and things like that to get a broader picture.

HR It is in its very early days. In my new role I am not obviously so concerned with that and I havent been following the debate as closely as I might have been. I am not quite sure, I again see potential problems with it. I think I would say that the Trusts freedoms that we started out with in the early 1990s were gradually whittled away anyway and part of me would say that anything that restores some of those local freedoms and encouragements and opportunities has got to be a good thing. Equally, I would be disappointed if that were at the expense of those hospitals that werent Foundation Hospitals and there will again be some potentially perverse outcomes that werent intended unless we are very careful. But the debate is still being held very much at policy level between the Chancellor, the Prime Minister, and the Secretary of State and I shall watch it with interest.

HR But they havent decided what the freedoms will actually be whether they will be notional or real and so on.

HR Well there are 2 or 3 sort of guiding principles behind the Bristol Health Service Plan and they are very much consistent with the work that UBHT and North Bristol Trust have separately done and one of them for example would be that you dont do anything in the hospital that can be done as well or better in a community-based setting closer to peoples homes and the fact is we still do huge amounts of work on hospital sites that could be done just as well, if not better, closer to peoples homes. That is very important. Another guiding principle is we have learnt, through bitter experience in this City, that the mingling of emergency and elective work can be disastrous for the smooth through-put of planned work and in what we are doing now and in future, we are trying more and more to try and separate those two streams if we possibly can whilst recognising it wont be possible to separate them totally particularly in some of the smaller specialities, but if we can do that in some of the bigger specialities, it will make an enormous difference.

HR - That may mean merely having a separate facility on a main hospital site. The Eye Hospital would be a very good example at UBHT which is a stand-alone building but is not connected by underground corridors to the rest of the precinct, so you cant put medical emergencies in there. As a result the Eye Hospital is very productive, gets on and does it own work in a specialist environment and works very well. You may have something like that. Or you may decide to take them further away and put some free-standing centres for out-patient diagnostic day work and so on. You might decide to put them out in the Community.

HR South and West Bristol PCT would like to put a Diagnostic and Treatment Centre, perhaps doing day surgery as well as diagnostics and so on, in South Bristol which would meet I think the long-held ambitions that many people in that part of the world have for more and better health facilities in the South of the City because at the moment they have to travel in for almost everything apart from GPs and some community services.

HR Yes, that is raised whenever I talk in public about these plans. So yes, there is a decision to be made and of course, it has be cost-effective, and it wouldnt be cost-effective to put penny packets of surgical facilities all over the place. There has got to be a relationship, a trade-off between volume and cost efficiency and so on, on the one hand, and local access on the other, but one of the things we have to do is to tease out in our plans in the coming month, just how we best do that and certainly we would want to achieve a separation of elective and emergency work if we can. So those are some of the sort of guiding principles that we are working to and of course again those are very much the sort of thing the Government is urging the NHS to do.

HR I visited a Super Clinic in Auckland recently. It is two miles from a main hospital. They see 150 thousand out-patients a year in this centre now. They have recently opened 12 operating theatres. Soon to be up to 80 beds doing 1200 procedures a year already, day cases, endoscopies and so on and will keep extending it and the week before I got there, they had started doing hip and knee replacements as well. So it just goes to show that if you are sufficiently ambitious, you can take out a lot of planned work, and interestingly they told me that the senior medical staff had been amongst the most dubious about the concept when it opened 5 years ago, but now were amongst its strongest champions because they had experienced and felt the benefits of being able to go and do their clinics and do their day surgery lists and so on away from the interruptions and the pressures and so on and so forth and can get through a consistently high quality 3-4 hours of work and then return to the main base, but they could do it in a way that was programmed without interruptions and they could just get on with it in a dedicated purpose-built setting that had ample car parking and all the rest of it. Very interesting. So I have written a briefing note recently on that for the Chief Executives just to help us with our thinking locally about how ambitious we can be.

HR What we have done on this one Richard is we are very clear that before we put any options to public consultation, we must be sure that they can work, so we asked a group of Senior Hospital Doctors and GPs to give us their views on the sorts of functional relationships, the sorts of clinical specification, what should a modern hospital look like, feel like, work like and so on and a number of colleagues had some very well articulated ideas about the kind of building we would all want to see to deliver modern health care, spacious, airy, well laid-out, good public circulation space. You could imagine the sorts of things that would appear. And so we said to a group of architects, right, you go away and test for us please whether a complex and emergency centre as one of two hospitals or a very big complex and emergency centre that was the only hospital, could fit and not just fit, but fit well and have room for future expansion on the BRI site, Southmead site, the Frenchay site and we assume it can fit on a Greenfield site, for obvious reasons. That work is going on at the moment and we will have the answers within a couple of weeks, so when we actually go to the public and say the options are we could have a big hospital here or a big hospital here, we can say confidently that it will fit and what is more it will fit in a flexible and modern and attractive way. I dont know the answer yet though because the work hasnt been completed and clearly if the answer came back that the BRI precinct might be able to be the smaller complex and emergency centre, but it couldnt be the bigger one, and we are talking up to 2000 beds if we only have one hospital, then clearly we couldnt put that forward as an option for consultation. But that work is just being wrapped up in the next couple of weeks so that we report it to the Trust Board and the PCT Boards in November.

HR All of the sites of course have very inefficient use of space currently. All of them have lots of dead areas or internal areas that are not at all well-used. Some of them in the older buildings have ceilings that are much, much higher than you would use nowadays and therefore consume a huge amount of cubic volume unnecessarily and most of them, because of course they have grown up like topsy over many, many years, are remarkably inefficient in their layout. So actually any of the sites you could, if you raised it and started again, you could put what is actually on that site already in a much more efficient way and much smaller space. We have got three separate groups of architects working on it, so that we can compare and contrast their work and they can cri