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Last Updated: Sunday, 2 April 2006, 21:35 GMT 22:35 UK
Programme transcript
What follows is a transcript of Panorama: The Hospital That Failed Women, broadcast on Sunday 2 April 2006 at 2215 GMT on BBC One.

This transcript is based on a recording and because of the possibility of miss-hearing and the difficulty, in some cases of identifying individual speakers, the BBC cannot vouch for its accuracy.


PANORAMA: THE HOSPITAL THAT FAILED WOMEN

Panorama

The Hospital That Failed Women

Comm: This is the story of how an NHS hospital put a group of breast cancer patients at risk.

A vital part of their treatment was missed.

And increased the chances of their cancer coming back.

The hospital has known about this for years.

But it has never told the women or their families what happened. Or why.

Sarah Barclay Comm: We'd planned to broadcast this film last July.

Since then we've been involved in a lengthy battle with the hospital at the centre of it. A battle in which they've accused us of relying on bad science and threatened the professional reputation of a key medical expert who'd helped us.

The hospital has made repeated attempts to persuade the BBC that the film was not in the public interest. We believe it is. The film the hospital tried to stop is a story about how it failed some of its patients.

"The Hospital that Failed Women"

Comm: Our investigation began with what we thought was a simple question: had a group of breast cancer patients been put at risk?

The hospital at the centre of this film is Bradford NHS Trust.

Doctors and managers here have known for years that during the 1990s some patients were getting what's known as sub-optimal care.

It was a doctor who worked outside the hospital who first raised the alarm.

THE WHISTLE BLOWER

Comm:

Dr John Philip was the Director of the local breast screening service in Bradford in the early 1990s. This is the first time he's spoken publicly about his concerns surrounding breast cancer treatment.

Dr John Philip, Pennine Breast Screening Service 1988 - 2003

Dr John Philip: "I always felt that I could have done more to put right what I believe was a wrong in Bradford and I did my best but I failed."

Comm:

Dr Philip monitored women between the ages of fifty and sixty four whose cancer was diagnosed through the NHS breast screening programme.

When he compared the medical notes of some of the women treated in Bradford with those treated at other local hospitals, Dr Philip realised the Bradford team were treating women differently.

Dr John Philip: "In Bradford I noticed that only 2% of the women had received radiotherapy-I would have estimated that at least 50% of those women should have received radiotherapy

Sarah Barclay: "50% versus 2% in Bradford.

Dr John Philip: "Yes, yes."

Comm: It was a particular type of breast cancer treatment that concerned John Philip.

A pioneering treatment that spared women the trauma of losing a breast.

Breast conserving surgery was a two part procedure. The first stage involved surgery to remove the tumour. The second stage was radiotherapy - a critical part of the treatment which helped to prevent the cancer coming back.

Dr John Philip: "They should have received radiotherapy so I felt concerned about that group of women at that time."

Comm: By 1990, there was widespread international agreement among doctors that in the majority of cases breast conserving surgery needed to be followed up by radiotherapy to destroy any remaining cancer cells.

Without radiotherapy, women faced a much higher risk - about 30% - that their breast cancer would come back. With radiotherapy, the risk of recurrence fell to about 10 percent.

Professor Michael Baum was one of the pioneers of breast conserving treatment in Britain.

Prof Michael Baum, Professor Emeritus of Surgery

Professor Michael Baum: "The risk of not adding it to the surgery means a number of things. About a 30% chance of the disease coming back in the breast. That means two things to the woman immediately, she then in most cases has to lose the breast, so defeated the whole object that she started off with a) and b) she has to come to terms with breast cancer all over again. You know, she may, three years out, have forgotten about breast cancer, living a normal life and then - bang! It's all back! And then she's got to adjust again and that's cruel."

Comm: During more than a decade as Director of Yorkshire's Pennine breast screening programme, John Philip only had access to the medical notes of women whose cancer had been detected by his own service. But even in this group, Mr Philip believes he saw evidence which suggested that failing to give radiotherapy was allowing breast cancers to come back -the risk is highest in the first five years after treatment.

Dr John Philip, Clinical Director 1988 - 2003 Pennine Breast Screening Service

Dr John Philip: "I have personally seen six cases where there has been recurrent disease in the breast, where I had wondered whether that would have happened if they had received radiotherapy.

Sarah Barclay: "Did those women know what the risk to them might have been of not having had radiotherapy in the first place?

Dr John Philip: "No, I don't think that women would have known."

Sarah Barclay: "Would there have been any acceptable reason not to have been giving women radiotherapy after conservative surgery by the early 1990s?

Professor Michael Baum: "No. Outside of a carefully controlled clinical trial with very careful case selection, in other words entry into an experimental arm, no, simply no. The treatment was breast conserving surgery plus radiotherapy. The treatment wasn't breast conserving surgery full stop. That wasn't a treatment."

Comm: But in Bradford significant numbers of women seemed not to be getting this crucial second stage of breast cancer treatment. Concerned about the potential risks, John Philip decided it was time to show the data he'd collected to his medical colleagues. Their reaction surprised him.

Dr John Philip: "There was a reluctance on the part of the consultant colleagues to get involved in this discussion.

"There was also an effort to belittle my concerns. There was an attempt to say that the data was inaccurate."

Comm: But as far as Dr Philip was concerned, the data was accurate. It was supplied by local hospitals themselves as part of the regular national audit of breast screening services. It was officially collated under the names of nominated surgeons. In Bradford the surgical lead for breast cancer was Jeffrey Price. Mr Price didn't do every operation recorded under his name, but he was one of the surgeons who treated the highest number of breast cancer patients in the region.

Sarah Barclay: "Was there a time when Mr Price challenged your interpretation of the data or said you've got it wrong?

Dr John Philip: "No. No, I've no recollection of that at all.

Sarah Barclay: "Never?

Dr John Philip: "No."

Comm: In the early 1990s Mr Price accepts he was responsible for surgical decisions but he says that other cancer specialists in the team carried "primary responsibility" for radiotherapy referrals.

Comm: In 1994 John Philip raised the stakes. He put his concerns in writing and sent the data he'd collected to his boss.

THE WHISTLE BLOWER'S BOSS:

Comm: Dr Liz Kernohan was deputy director of public health in Bradford at the time. She replied:

Actress voice-over: "Dear John, thank you for sight of your "draft" confidential paper┐which unfortunately seems to confirm a problem in Bradford"

Comm: Dr Kernohan acknowledged that the data was worrying. And she agreed that for women who'd had breast-conserving surgery, it appeared to reveal Actress voice-over: " a very low radiotherapy... rate."

Comm: Dr Kernohan seemed to be in no doubt about the potential risks involved.

Actress voiceover: "There is also a larger problem about what to do with the women who haven't received radiotherapy┐We clearly need to act fairly quickly now on the contents of your paper and I will facilitate progress in whatever way I can."

Comm: The whistleblower waited to hear again from his boss.

Sarah Barclay: "What happened?

Dr John Philip: "To the best of my recollection nothing happened."

Comm: Dr Kernohan is now the director of public health of a primary care trust in Bradford. We wanted to ask her what she had done to investigate Dr Philip's concerns. She sent us an email saying:

Actress voiceover: "I do not consider it appropriate for me to take part."

Comm:- In 1995, concerned that things weren't moving swiftly enough, John Philip went to see David Jackson, Bradford Trust's chief executive and its medical director, Dr Michael Smith to tell them women were at risk.

Dr John Philip: "I expressed my concerns that the management of breast cancer patients in Bradford was out of line with the management in the other districts. So I discussed this with both of them."

Sarah Barclay: "And what was their response?

Dr John Philip: "Their response was that they were going to address these issues but there appeared to be a lack of urgency."

Comm: The Trust says it is not aware of a documented record of such a meeting taking place.

But according to Dr Philip, raising concerns about patient safety did not go down well with the Trust management at that time.

Dr John Philip: "Looking back I think I was a bit na´ve. Subsequently I became conscious in Bradford that there was a culture of fear and intimidation among consultant colleagues."

Comm: What he couldn't know was that his sense of a culture of fear and intimidation would later be supported by a senior manager at the hospital.

THE INSIDER

Comm: One man who says he was told what was going on behind the scenes in the Trust is the former head of human resources, a senior member of the management team. This man did not wish to be named but claimed in a witness statement written in 2002 that John Philip's attempt to blow the whistle almost cost him his job.

Actor: " I learned that Mr Philip had met with a hostile reception for doing so."

Actor: "I was informed by other board directors that the matter was regarded as unfinished business."

Actor: "They said that Mr Philip had been party to the criticism of the breast cancer services in the Trust and had been lucky to survive the attempt to get rid of him."

Comm: Last July, we came to Bradford to put this and other concerns about the care of breast cancer patients to two doctors put forward by the Trust. The first was [Operations] Medical Director John Wright.

Dr John Wright, Operations Medical Director, Bradford Hospitals NHS Trust.

Sarah Barclay: "We've seen a witness statement from the Trust's former Director of Human Resources which says that he was told that Mr Philip had been lucky to survive the attempt to get rid of him as a result of raising concerns about breast cancer treatment.

Dr John Wright: "I can't comment on that, I mean that seems to be one person's opinion and there's no documented record about any attempt to undermine Mr Philip."

Comm: But as we were about to discover, there were doctors working inside the hospital who shared John Philip's concerns about breast conserving treatment. One of them was the second doctor put forward by the Trust to answer our questions. Dr Chris Bradley spoke frankly about what he'd found after he arrived in 1993.

Dr Chris Bradley, Consultant Medical Oncologist Bradford Hospitals NHS Trust

Sarah Barclay: "What did you think about the practice when you arrived?"

Dr Chris Bradley: "Well it was clear to me when I came that this was out of step.. It was clear.. became... by early '94, that patients weren't getting the amount of radiotherapy that was given, was less than I would have expected to happen at that time.

Sarah Barclay: "And who was responsible for making that decision?

Dr Chris Bradley: "Well it was the decision of the team and I.. and I discussed it with the whole team.. tell me why we're doing a practice this way and the team individually were.. were individually and as a whole were very clear about that, it was about the concerns about the risk of toxicity. Now you.. I may feel, was that.. was the concern over stated...

Sarah Barclay: "Did you feel that?"

Dr Chris Bradley: "I think it was and a result of that we started to discuss in great detail, have we got the treatment right for patients.

Comm: Concerns had been raised nationally about the risks of toxicity. The breast cancer team was also concerned about scarring. But by the early 1990s techniques were improving and teams working in other hospitals in Yorkshire were using the same machines but giving far more women radiotherapy. The question was why?

Dr Chris Bradley: "I think the views of the team in Bradford at that time was coloured primarily by what their patients were telling them about what they experienced.

Sarah Barclay: "Surely it's only up to the patients up to a certain point, it's up to the breast cancer team to make the best possible decision for that patient based on the best available evidence at the time.

Dr Chris Bradley: "Absolutely, so they tried to make a balanced judgement. I think it is arguable whether that judgement was as balanced as it might have been back then.

Sarah Barclay: "What do you mean?

Dr Chris Bradley: "I think they were out of step from.. from the consensus view of the majority of their colleagues, I don't think they'd argue that for a moment."

Comm: Just how far out of step the medical team in Bradford was compared with their colleagues in other hospitals became clear in 1995.

Dr Michael Smith, then medical Director of Bradford Trust, got a phone call from the local Cancer Registry, warning him that the hospital had been officially identified as what they call an outlier.

The Yorkshire Cancer Registry was preparing to publish a report. It was based on confidential medical information on thousands of breast cancer patients treated between 1976 and 1992.

It named Bradford as having the lowest radiotherapy rate in all but three of those 17 years.

THE MEETINGS

Comm: It was now 1995. The Government was about to launch an ambitious plan to stamp out postcode variations in cancer treatment across the country.

In Bradford a series of meetings took place to discuss a timetable for change.

Comm: In a witness statement written four years ago, Dr Michael Smith recalls that there were at least five discussions with lead surgeon Jeffrey Price during 1995 and 1996 at which they :

Actor voiceover: "discussed the pros and cons of radiotherapy at some length."

Actor voiceover: "I had taken this up personally with Mr Price over the course of several meetings to ensure that he was "on board" with the whole issue of radiotherapy."

Dr Chris Bradley, Lead Clinician Cancer Services Bradford Hospitals NHS Trust

Sarah Barclay: "In 1995 there were conversations going on in this hospital between the Medical Director and Jeffrey Price, to try and discuss the pros and cons of radiotherapy. Surely by 1995 he should have known what the advantages were?"

Dr Chris Bradley: "I'm not sure it was all of the meeting it but certainly was a lot meetings and what we were and what we were doing was discussing, as I said before, how we went from where we were then to where we wanted to be in terms of implementing...introducing use of radiotherapy and lots of other things.

Sarah Barclay: "But five separate meetings Dr Bradley, this was accepted medical practice by then."

Dr Chris Bradley: "I don't think at all there were five separate meetings to convince him of that. I think there were a whole series of meetings - in practice many dozens of meetings - to plan if we were deciding we want to give radiotherapy to all the patients who need radiotherapy how do we make that happen."

Comm: Mr Price's lawyers insist that the appropriate use of radiotherapy was only part of the discussions with Mr Smith and that he had "no issue" with the latest official recommendations.

But patients in Bradford knew nothing of the discussions going on behind the scenes. They thought they were getting the best care all along.

What they didn't realise was that where they lived could make such a difference. Does It Matter Where you Live? Comm: It wasn't just doctors in Bradford and the local cancer registry who were concerned that women weren't getting the best possible treatment.

This is Richard Sainsbury. At that time he was one of the most experienced breast cancer surgeons in Yorkshire.

Dr John Philip, Clinical Director 1988 - 2003 Pennine Breast Screening Service

Dr John Philip: "He had access to information that I didn't have access to because he had an overall responsibility for collecting data and analysing data of cancer patients in the Yorkshire region and he confirmed the concern that I had that the usage of radiotherapy in Bradford for people who had undergone conservative management was much less than the average for the Yorkshire region."

Source: British Cancer Journal 1995 Comm: Richard Sainsbury was one of the authors of an influential report on breast cancer treatment published in 1995. It was called "Does It Matter Where You Live?" The answer was yes.

Drawing on Yorkshire Cancer registry data , it highlighted the district with the lowest radiotherapy rate in Yorkshire. It didn't name it. Only insiders knew it was Bradford. Richard Sainsbury and John Philip met to discuss their concerns.

Dr John Philip: "Trying to see the picture of that woman behind the figures that there is somebody walking the streets of one of our towns, who possibly would have a higher risk of that disease coming back which would be devastating for the women. But it was personally very upsetting to both of us."

Comm: At this point you might have expected to meet one of the women involved in this story - a woman who had breast conserving surgery in Bradford in the early 1990s but no radiotherapy.

The reason you won't is because strict medical confidentiality rules prevent anyone in this film disclosing names or individual case histories. We don't know who the women are. And neither do they. But the hospital has known all along.

Sarah Barclay: "How long did it take between identifying that there was a problem and making sure that Bradford in terms of radiotherapy referrals was in line with the rest of the region?

Dr Chris Bradley: "I think we started to change it almost right away. I think we changed it substantially in 1994 and by 1995 we're already coming pretty close in line."

Comm: But as we'll discover, medical data analysed for the first time for Panorama, told a different story.

Source: Improving Outcomes in Breast Cancer 1996 Comm: The NHS published guidelines in 1996 that highlighted the risk of not carrying out both stages of breast conserving surgery. Without radiotherapy they concluded the risk of breast cancer coming back: "can be as high as 30% after five years - four times the rate found after radiotherapy." Official confirmation that the treatment policy in Bradford could have potentially far reaching consequences for patients.

Sarah Barclay: "Were those women informed that they hadn't had the best available treatment at the time?

Dr Chris Bradley: "No, I don't think there was any basis. I didn't feel there was any basis for informing patients that treatment policies had changed and that we considered our new treatment policies better than our old treatment policies."

Sarah Barclay: "Surely though you might argue that the women who hadn't had radiotherapy had a right to know and there was still a possibility that they could have had radiotherapy if that was appropriate?"

Dr Chris Bradley: "It wouldn't have made any material difference with... All patients who had received any sort of treatment within the breast team were followed up very regularly by the team. Three monthly, six monthly follow up appointments. Any problems, any problems with local recurrence of their cancers would have been known about already."

Sarah Barclay: "But that would have been too late wouldn't it, if you waited until the cancer came back, that was too late?"

Dr Chris Bradley: "But at that time, any patients who had had a problem, it would have been known about and dealt with already. If the issue is should we go back, talk to patients who haven't had a problem and say, a problem might occur, again I don't think that would make any material difference or serve any useful purpose at all."

Comm: By 1998, senior managers were looking urgently for a second consultant surgeon to expand the breast cancer service in Bradford.

The Hunt For A Second Surgeon

Comm: We've discovered evidence which suggests that Jeffrey Price, the lead breast surgeon in Bradford, had concerns. A confidential memo written by the Trust's chief executive, David Jackson, says:-

Actor voiceover: "The appointment of a second breast surgeon has been a high priority within the Trust for some time but the principle has met with considerable resistance from the existing breast surgeon."

Comm: In April 1998, an experienced woman candidate from Oxford withdrew her application to become the second breast surgeon in Bradford at the eleventh hour. An internal memo written by the Trust chief executive reveals she believed that Actor voiceover: "if appointed she would meet considerable resistance in seeking to develop the breast service along modern lines"

Comm: Dr Smith, the Trust's medical director, was furious and appears to have blamed Jeffrey Price. Source: Witness Statement, Employment Tribunal 2002 Actor voice-over: "I was very angry indeed about the withdrawal of this candidate. I telephoned Mr Price and spoke to him and then arranged to meet with him.

Comm: The interviews were cancelled. Through his lawyers Mr Price says he supported a new appointment and was disappointed when the candidate withdrew but didn't know why she had done so.

His lawyers say the department was already set-up along modern lines and shouldn't have caused any concern.

The Man Who Got The Job:

Archive: Robert Phipps: "What I'm going to do is just examine you quickly now right and I'm not going to hurt you."

Comm: Robert Phipps, a British surgeon who'd been working in New Zealand applied to join the team in Bradford. Another chapter in the story of its troubled breast cancer service was about to begin.

Robert Phipps, Consultant Surgeon,Bradford Hospitals NHS Trust 1998 - 2000

Robert Phipps: "I had an interview with the Medical Director and the Director of Patient Care, and I asked various questions, and it was also put across, that if they didn't, in fact, improve their game, the cancer status of that hospital was likely to be removed with funding problems for the Trust."

Comm: Robert Phipps was offered the job of surgeon with a special interest in breast cancer. He started work in Bradford in September 1998.

Sarah Barclay: "What did you hope that his appointment would achieve for the breast cancer service in Bradford?"

Dr Chris Bradley: "We hoped that it would provide a second person to help contribute to the service fairly straight-forwardly."

Sarah Barclay: "And did he?"

Dr Chris Bradley: "It didn't work out well. I think he didn't gel with almost any of the breast cancer team and I'm not sure he made a positive contribution to breast cancer in Bradford."

Comm: Over eighteen months, relationships between Robert Phipps and the hospital became increasingly strained. Questions had been raised about Mr Phipps' professional background. And he'd raised concerns about whether the breast cancer service in Bradford was providing the best possible care for women.

Comm: In the Spring of 2000 Mr Phipps says he became aware of a number of women who'd had breast lumps removed but whose cancer had come back.

Robert Phipps: "There were three patients that came back within the space of 1-2 weeks, and recurrent disease is not common, and when I looked into that it became apparent that they hadn't been given radiotherapy which of course is absolutely essential when treating breast cancer by just removing the tumour. And that's when I was alerted to a potential problem and looked into it."

Comm: It led to a remarkable meeting with the doctor who'd tried to blow the whistle years before - John Philip, the man in charge of the local breast screening service.

Dr John Philip: "He brought case notes to my room. He had individual examples of women whose cancer had come back .. we both felt quite agitated and quite emotional about individual women for whom the recurrent disease probably could have been delayed or prevented."

Comm: Then Robert Phipps went to see Richard Sainsbury, the breast cancer surgeon whose report had asked "Does it matter where you live?"

Robert Phipps: "He just smiled and said "Well tell me something new.

Sarah Barclay: "Were those his words?"

Robert Phipps: "Yes."

Comm: Three doctors had now reached similar conclusions at different times. What this meant for the women who hadn't had radiotherapy was that if their breast cancer came back, they faced a mastectomy, the very thing that breast conserving surgery was intended to avoid.

Comm: On 5th May 2000, Robert Phipps wrote to the Trust's Medical Director, spelling out the potential legal consequences for the Trust.

Robert Phipps voice-over: " The concern for the Trust must be the potential litigation from a group of patients who have not had appropriate treatment and were not made aware of an increased risk of local recurrence if radiotherapy was not given."

Comm: What prompted Robert Phipps to write this letter has been the subject of bitter disagreement between himself and the Trust ever since. Mr Phipps says he was doing what any responsible doctor should if he believed patients were at risk.

The Trust says he was using the issue of radiotherapy to deflect their inquiries into his professional background.

Comm: On the 28th June 2000, Robert Phipps was summoned to a meeting at Trust headquarters.

Sarah Barclay: "What happened at the end of the meeting?"

Robert Phipps: "I was escorted off the premises and told not to return to work."

Comm: In September 2000, Robert Phipps was sacked. He was later found guilty of serious professional misconduct for misrepresenting his medical background and suspended by the General Medical Council for a year.

Robert Phipps, Consultant Surgeon,Bradford Hospitals NHS Trust 1998 - 2000

Sarah Barclay: "Some people might just say that you're a troublemaker Mr Phipps."

Robert Phipps: "Well I don't think that could be the case for the simple reason that I didn't go to the media. I raised those concerns in house - I checked those concerns as best I could with other senior people."

Dr John Wright, Operations Medical Director Bradford Hospitals NHS Trust

Sarah Barclay: "Robert Phipps argues that he was sacked from his post here because he blew the whistle about radiotherapy rates in Bradford, is that correct?"

Dr John Wright : "No. Our concern is that this is a smoke screen and the danger is by taking things like this seriously, that you undermine and undervalue people's genuine concern about improving quality of care."

Comm: The NHS has always had a difficult relationship with those characterised as whistleblowers.

But what matters - is what truth there is to claims about patient welfare.

What we wanted to know was what had happened to the women who hadn't had radiotherapy? This was what Dr Chris Bradley said last July about the women who'd been treated before 1995.

Dr Chris Bradley, Lead Clinician Cancer Services Bradford Hospitals NHS Trust

Sarah Barclay: "So have any of the women who didn't have radiotherapy after breast conserving surgery here in the early 1990s had unnecessary recurrences in your view?

Dr Chris Bradley: "There is a risk they may have had a larger number of recurrences because of it ... the lack of radiotherapy and they will have however been spared the toxicity of radiotherapy.

Sarah Barclay: " But their cancer may have come back?"

Dr Chris Bradley: "There is a possible...cancer can always come back. I am going to accept entirely that radiotherapy can reduce the risk of it coming back.

Sarah Barclay: "So there may be some women who did not have radiotherapy here whose cancer has come back and perhaps it needn't have done if they'd been treated somewhere else?"

Dr Chris Bradley: "There may have been some recurrences of breast cancer because of that difference in policy which we then have been treating appropriately. The patients..."

Sarah Barclay: "By that time it's too late isn't it Dr Bradley, their cancer will have come back and the treatment for recurrence is very often mastectomy. The one thing they would have hoped to avoid by having breast conserving surgery in the first place."

Dr Chris Bradley: "The effect.... if a breast cancer comes back again you need effective treatment and in some of those patients radiotherapy is exactly the... sorry I beg your pardon, mastectomy is essentially exactly the treatment that's required."

Sarah Barclay: "So there may have been some women who've had unnecessary mastectomies as a result of this policy?"

Dr Chris Bradley: "No they were mastectomies as the optimum treatment for them in the circumstances."

Sarah Barclay: "No, but if their cancer has come back as a result of not having radiotherapy and they have had to have a mastectomy, that as far as they were concerned would have been an unnecessary mastectomy which they might have avoided if they'd had radiotherapy, isn't that the issue?"

Dr Chris Bradley: "You are right , there could be women in that category largely out numbered by the number of women in the other category who didn't have radiotherapy and did not have recurrence and were therefore spared the toxicity of radiotherapy."

Sarah Barclay Comm: The bottom line was - the hospital didn't know. It was now at least ten years since they'd been told there was a problem in Bradford and ten years since they claimed to have put it right. But as they'd decided there was no need to identify or inform the women who might have been put at risk they couldn't tell us what had happened to them.

Comm: But there was another source of information, one which had been available all along. Data which is not publicly available. It contains the medical secrets of individual hospitals and doctors. It was this data which led us to "Surgeon 39".

The Story of "Surgeon 39"

Prof Michel Coleman, Dep Chief Medical Statistician Office for National Statistics 1995 - 2004

Comm: Analysing the performance of an individual doctor or medical team remains one of the most difficult and controversial areas of medicine. We needed the help of an expert.

Professor Michel Coleman is a medical statistician who specialises in investigating patterns of cancer treatment and survival. He is also a Department of Health advisor who believes there should be more transparency in the use of medical data to improve patient care.

Professor Michel Coleman: "Openness about the outcome of treatment in the NHS is important so that patients are clear that the evidence of survival, for example, or outcome of treatment is understood and is being acted upon by managers. "

Comm:- Professor Coleman asked the Yorkshire cancer Registry which had first identified a problem in Bradford, to release information on almost thirty thousand women with breast cancer who'd been treated in hospitals in Yorkshire between 1982 and 2003.

Data that would reveal the treatment patterns of individual surgical teams and long term outcomes for the women.

Professor Michel Coleman: "The data from the Northern and Yorkshire Cancer Registry are amongst the best in the country in terms of completeness and quality when it comes to treatment and survival. "

Neither individual surgeons nor the women assigned to them were identified by name. But each surgeon had a number. When the analysis was finished, one number stood out. "Surgeon 39".

Professor Michel Coleman: "Surgeon 39" was responsible for just over 2000 women with breast cancer during the period 1982 to 2003 in the Yorkshire region out of a total of 28,000 women with breast cancer treated in the NHS in the same region during that period, and only one other surgeon was responsible for more women with breast cancer in the same period.

Comm: "Surgeon 39" was the identifying number for Jeffrey Price, the consultant in Bradford. But because of the way medical data is organised, the fact that a patient has been assigned to a particular surgeon does not mean that this surgeon is responsible for all of their care.

Bradford Trust told us that until 1995 radiotherapy decisions were made by an "informal team" of which Mr Price was a member and that after 1995 he made no decisions about radiotherapy at all. Mr Price's lawyers told us that at no time was he "primarily responsible" for radiotherapy.

Comm: But behind this elaborate chain of responsibility lay the story of the women themselves, hidden in the medical data. It was a story which revealed that women assigned to the "Surgeon 39" team in Bradford were treated very differently from women treated in other hospitals in Yorkshire.

Professor Michel Coleman: "To see such a strikingly different pattern of breast conserving surgery and radiotherapy after breast conserving surgery for women treated by this surgeon than all other experienced surgeons then I think one has to draw one's own conclusions."

Comm: It was the first time the data held by the cancer Registry had been analysed in this way. We gave the Trust time to consider Professor Coleman's report.

Dr John Wright, Operations Medical Director Bradford Hospitals NHS Trust

Dr John Wright: "The analysis that you've had undertaken is something that we welcome because there's a vacuum in this sort of health outcomes data in the Health Service, we just don't get this information fed back as much as we should."

Comm: But this was just the prelude to an astonishing attack on the man who'd tried to answer the question the Trust itself had chosen not to ask.

Dr John Wright: "I don't accept the report as it stands, it's deeply flawed"

Sarah Barclay: "Are you saying that Professor Coleman's report is bad science?"

Dr John Wright: "I am saying it's bad science."

Comm: The Trust's lawyers then threatened to report Professor Coleman, a qualified doctor, to the General Medical Council, the body which regulates the medical profession, if he refused to withdraw or change his report.

Professor Michel Coleman: "In more than 25 years of cancer research I have never seen such a personal and vituperative attack on what I have done my best to ensure is consistently good science."

Comm: The Trust had already asked another medical statistician, Professor Trevor Sheldon, to review the report. He concluded: "Professor Coleman is not justified in singling out "Surgeon 39" as being a poorly performing breast cancer surgeon." "The quality of the data and the analysis is not of the same standard that has been used in high profile cases of poor performance such as the Bristol and Shipman inquiries." Comm: These were serious concerns. So we gave Professor Coleman's report to the statistician who'd been closely involved in those two public enquiries and asked him to review it.

Comm: Dr David Spiegelhalter was an expert advisor to the Shipman inquiry. And he led the team of statisticians who investigated what went wrong in Bristol where an unusually high number of babies died after heart surgery during the 1990s. After a detailed examination of Professor Coleman's work, Dr Spiegelhalter was ready to give us his verdict. Was the Trust right to describe Coleman's report as "bad science"?

Dr David Spiegelhalter FRS Biostatistics Unit Medical Research Council

Dr David Spiegelhalter: "I don't think I would go along with that. I think Professor Coleman's done a good job on the data that's available and this is the best available registry data that is there on breast cancer and so I would not agree that it's bad science. This is comparable to the analyses that we carried out for Bristol and Shipman inquiries."

Comm: In both those cases, medical data contained vital clues which helped identify what had gone wrong.

We can now reveal what Bradford NHS Trust didn't want you to know. How long were women being put at risk?

Comm: So did women with invasive breast cancer assigned to the "Surgeon 39" team get sub-optimal care? Professor Coleman saw striking differences.

Professor Michel Coleman: "The time scale here is from 1982 'til the end of 2003, so a 22 year period and on this scale is the proportion of women given radiotherapy after breast conserving surgery. This is the curve here for all other surgeons, this is the curve for "surgeon 39". "

COMM: When he compared "Surgeon 39"'s team with the 19 other experienced breast cancer teams in Yorkshire who had treated an average of 1,000 patients each, the difference was even more stark.

Michel Coleman, Professor of Epidemiology, London School of Hygiene

Professor Michel Coleman: "If we compare the women treated under this surgeon with breast conserving surgery with those treated by all the other experienced surgeons, 46% of surgeon 39's patients were given radiotherapy after breast conserving surgery. For all other experienced surgeons the value is 84% so many many fewer women were treated with radiotherapy.

Sarah Barclay: "How significant a difference is that?"

Professor Michel Coleman: "It's a very, very large difference."

Comm: But what these figures also suggest is that it took until at least 1999 for Bradford Trust to bring its radiotherapy rates into line with the average for other hospitals in the region - far longer than they'd told us when we interviewed them last July.

Dr Chris Bradley, Lead Clinician Cancer Services Bradford Hospitals NHS Trust

Dr Chris Bradley: "I think we changed it substantially in 1994 and by 1995 by the time the NYCRIS report highlighted what were then historical differences we were already coming pretty close in line."

Comm: "But Professor Coleman's analysis had revealed that in 1996 - a year after the Trust claimed to have solved the problem - radiotherapy rates fell to 36% compared with an average of 83 percent for all other teams across the region."

Sarah Barclay: "The Trust says that by 1995 it had identified that there was a problem and that it was coming into line with other hospitals nearby. Is that correct from the data you've seen?"

Dr David Spiegelhalter: "Well they were certainly increasing the proportion of women receiving radiotherapy by 1995 but there was still substantial divergence from the practice of their colleagues right up until the end of the 1990s."

Dr Spiegelhalter supported Professor Coleman's conclusions about the women who'd been assigned to the "Surgeon 39" team.

Dr David Spiegelhalter: "Each blob here represents a surgeon and their team and the blue blob is "Surgeon 39". We can see between 1994 and 1998 there's been a considerable change in practice of "surgeon 39". They're now giving radiotherapy after about 50% of the time But still, compared with the other surgeons where the rates are well over 80% and a strong consensus that this is the standard treatment. So they're still really an outlier even in 1994 to 1998."

Comm: The analysis suggested more women were put at risk and for much longer than the Trust had previously admitted. We asked one of the pioneers of breast conserving surgery, how quickly he would have expected radiotherapy rates to rise.

Prof Michael Baum, Professor Emeritus of Surgery

Professor Michael Baum: "Within 12 months."

Sarah Barclay: "That quickly."

Professor Michael Baum: "That quickly ┐ but I've seen no evidence that the trend was corrected within 12 months. From the data I've seen it took four of five years to correct the practice there."

Sarah Barclay: "Was that acceptable?"

Professor Michael Baum: "I don't think so. Others were getting the radiotherapy and this practice was not."

Comm: Then we asked Professor Baum whether it was reasonable to remain out of step with accepted medical practice for so long.

Professor Michael Baum: "There may be the odd anecdotal case where it could be excused but as a general policy I find it inexcusable, and the reason for that, you only have one chance really to get it right. With the current state of knowledge you don't really get a second chance of getting it right.

Comm: So had Professor Coleman's analysis revealed how many women might have been denied that critical "one chance" by not being given radiotherapy?

Professor Michel Coleman: "About 150 women who one might have expected to have radiotherapy under this surgeon if his practice was similar to the average of all others. And most of those 150 are in the period 1988 to 1998. "

Comm: We sent Dr Spiegelhalter's report to Bradford Trust. In January we went to see them again to ask whether they would now accept that the "Surgeon 39" team had remained out of step for far longer than it had previously claimed.

Dr John Wright, Bradford Hospitals NHS Trust

Sarah Barclay: "Do you or do you not accept that this Trust remained an outlier for radiotherapy after breast conserving surgery until at least the period beginning 1999 Yes or no?"

Dr John Wright: "I am saying we were an outlier up until 1995 and then there is no evidence statistical or clinical that we were an outlier."

Sarah Barclay: "You don't accept it?"

Dr John Wright: "There is no evidence.

Sarah Barclay: "So what went wrong in 1996 when the rate was just 35 percent."

Dr John Wright: "You'll see the trend from 1995 increasing year on year and in some years we're going to be less than average and some years we're going to be more than average. So if you look at 2002 and 2003 our referral rates are higher than other hospitals. It doesn't mean that they are under-referring."

Comm: The Trust refused to accept Professor Coleman's analysis. Instead, they asked the Cancer Registry to do the sums differently, focusing on just the three years between 1994 and 1996. This analysis concluded that "Surgeon 39" was " within the accepted range for all years ."

The experts who advised us stand by the conclusions they reached after much more extensive analysis. The war of statistics had only just begun.

So did it matter where you lived?

Comm: It was analysis of survival data for the "Surgeon 39" team which was to prove most controversial of all. This data can reveal how long patients live after being treated by one medical team compared with another. Its public use is hotly contested by doctors and hospitals. Professional reputations are at stake.

Sarah Barclay: "Is it possible to say that women have died after being treated by "surgeon 39" and his team who might not have died if they had been treated by an equally experienced team somewhere else?

Professor Michel Coleman: "Yes, there is evidence of higher mortality amongst the women treated for breast cancer under this particular surgeon."

Sarah Barclay: "What does that mean in terms of actual numbers of women?"

Professor Michel Coleman: "I think the simplest way to summarise it is that somewhere between 30 and 40 more women have died from breast cancer after treatment under "surgeon 39" than one would expect, comparing his patterns of treatment to those of other experienced surgeons and after taking account of what is possible to take account of in terms of age and patterns of whether they're rich or poor, other factors such as that.

Sarah Barclay: "30 to 40 more women?"

Professor Michel Coleman: "Yes."

Comm: We asked Dr Spiegelhalter for his view of the survival data. He was cautious.

Dr David Spiegelhalter FRS Biostatistics Unit Medical Research Council

Sarah Barclay: "Have more women died after being treated by "surgeon 39" and his team than might have died if they'd been treated somewhere else?"

Dr David Spiegelhalter: "Well, of course, that's a difficult question to answer, especially with any precision. Professor Coleman's analysis suggests that during the period '94 to '98 that the team of "surgeon 39" was the highest risk team in...among the experienced surgeons being analysed and that there was significant excess...excess mortality. "

Comm: Professor Coleman's analysis included all of the women with invasive breast cancer assigned to the "Surgeon 39" team, not just those who'd had breast conserving surgery. But the data couldn't tell him who the women were or why they had died. Survival data alone isn't enough to make definitive judgements about the quality of medical care. The analysis had simply revealed that under "Surgeon 39" team there were more deaths than expected - not why.

Michel Coleman, Professor of Epidemiology, London School of Hygiene

Professor Michel Coleman: "The pattern of evidence is quite strong, it shows that the higher risks occurred mainly in women treated with breast conserving surgery as opposed to mastectomy and mainly in the period 1994-1998 - and that's the period when radiotherapy was being given much less often following breast conserving surgery. So it doesn't amount to proof but the pattern of evidence gives quite a strong lead."

Sarah Barclay: "So how far can data like this give us the true picture about the performance of a particular surgeon and the people that he or she worked with?"

Dr David Spiegelhalter: "Well it can describe differences in practice, which I think are fairly clearly done in this case. It's much more difficult to assign the consequences, the outcomes to these differences in practice."

Source: Early Breast Cancer Trialists' Collaborative Group Overview 2005 Comm: Last year The Lancet published a major study based on 42,000 women in medical trials. It revealed for the first time that radiotherapy after breast conserving surgery improved survival after 15 years by five percent.

The Trust argues that because the excess mortality identified in Bradford was seen only five years after women were treated - it can't be explained by a lack of radiotherapy.

But a key finding of the study remains - for every four cases of recurrence prevented by radiotherapy one death is avoided.

The survival of women treated as long ago as the early nineties could still be affected today.

Sarah Barclay: "Would you say there's now enough evidence to justify the hospital Trust concerned launching some sort of investigation of its own?"

Professor Michel Coleman: "That's a judgment they must make. If I were in their position I would."

Sarah Barclay: "Why?"

Professor Michel Coleman: "Because I think it's important that women or the relatives of the women who unfortunately have died have an opportunity to discover if their particular mother, sister, daughter was appropriately treated."

Comm: In January we went to discuss the weight of evidence which had emerged with the Trust. They had some news for us.

Dr John Wright: "Now because of the concern that the BBC has raised about this issue we've instigated an in depth audit. Now you can't just rely on crude statistics to make judgments about this. What you need in a clinical situation is to do an extensive audit and we have taken this very seriously."

Comm: More than ten years after concerns about radiotherapy rates were first raised in Bradford, the Trust told us it had decided to look through the medical notes for a thousand women for the period 1995 to 2000 to find out what treatment they'd received and whether it was appropriate.

Dr John Wright: "All the women who didn't have radiotherapy, didn't have radiotherapy for clear reasons. They didn't fulfill the guidelines. They were too old or frail or they refused treatment."

Comm: We hadn't seen the audit and it had not been independently reviewed. But according to the Trust, the news was good.

Dr John Wright, Operations Medical Director Bradford NHS Hospitals Trust

Dr John Wright: "Of all the women there has only been one case of local recurrence. One single case in all these women. We'd expect about 20 to 30 percent. So this is really excellent news for local patients. That woman is alive and well. She was successfully treated after her local recurrence was identified."

Sarah Barclay: "Do the patient notes that you have include women who may have moved away, who may have dropped out of the follow-up process, or who may no longer be included in the breast screening programme? Have you been able to trace all the women who were treated by ...?

Dr John Wright: "I can't answer that. As I say, this is┐

Sarah Barclay : " current health status is."

Dr John Wright: "As I say, this is recently completed"

Sarah Barclay: "Who carried out the audit?"

Dr John Wright: "The oncology team."

Sarah Barclay: "Has it been independently reviewed?"

Dr John Wright: "We'd be happy to have it independently reviewed."

Comm: But the audit was selective. For instance it didn't include the notes of the 183 women with invasive breast cancer who had breast conserving surgery in the 13 years up to 1995. Just 17 had radiotherapy.

Two days ago the Trust sent us an email. It said that when Dr Wright gave this interview the audit was still in draft form. He was wrong to say there was only one case of recurrence in the group they looked at. In fact our understanding is they've found four.

The audit has still not been independently reviewed. The hospital insists there is no evidence of poor practice.

So back to that interview with Dr Wright. Next we asked him about the evidence suggesting more patients assigned to the "Surgeon 39" team had died than might have been expected.

Dr John Wright: "The data that we've got from the statistics which show out of the 20 years period there's one five year period where he's an outlier when it comes to survival. This isn't consistent, we then have to look at more detail, dig below the statistics and find out if there's any concern from his clinical care and we've done that through the case note audit and we haven't found anything."

"And so therefore what we have to do is turn to the statistics as to why that may be the case. It might be chance it might be due to case mix. It might be due to a very select group of comparisons. Twenty surgeons rather than 140."

Sarah Barclay: "Do you accept that it might be due to a problem with this particular "surgeon" and that is the question that is being asked.

Dr John Wright: "That is one of the explanations."

Sarah Barclay: "It's a possible explanation."

Dr John Wright: "But we need to have proof of that and we haven't got that and we certainly haven't got that from the audit. We haven't found anything to suggest that."

Comm: Then we asked a final question - this time it was a really simple one. We wanted to know what had happened to Jeffrey Price, the surgeon who had been a member of the team known as "Surgeon 39".

Sarah Barclay: "Is Mr Price currently treating patients at this Trust?"

Dr John Wright: "I don't know. You need to ask one of the oncology team.

Sarah Barclay: "I'm asking you Dr Wright because you're here as a representative of the Trust and I imagine that you can answer the question is Mr Price currently treating ...

Dr John Wright: "Can I seek counsel on that because I'm not too sure actually so I probably just need to check. Can I check actually, I'm not too sure if he is, is he?

Trust press officer: "I don't know John.

Dr John Wright: "Can you find out? I'm not too sure to be honest, I don't know but I'm happy to find out.

Trust Press Officer: "We'll come back to that later on."

Dr John Wright: "Could somebody find out?

Comm: Later we were told that Mr Price had stopped working for the Trust at the end of 2005. The Trust says its current breast cancer service was highly commended in an independent review published just last year.

Comm: It has been more than a year since we asked that simple question; were breast cancer patients in Bradford put at risk, for how long and what were the consequences? A year in which Bradford NHS Trust has tried repeatedly to get us to stop our investigation because it claimed it would damage public confidence in cancer care.

Prof Michel Coleman: "It has been harder to do this than we expected. The solicitors for the Trust threatened to refer me to the GMC for professional misconduct a threat they still haven't withdrawn eight months later. Maybe shooting the messenger and denying the problem was easier than facing the consequences. TV documentaries are clearly not the best way to monitor treatment standards in the NHS, but then the normal methods don't appear to have worked in Bradford."

Comm: John Philip, the doctor who first raised concerns about breast cancer treatment in Bradford, has retired from the NHS. He still believes doctors should be able to voice their concerns about patient care without fear of recriminations.

Dr John Philip: "Being a professional does not mean covering our own back all the time, and I think I would encourage people to question, to debate, not to be bullied, not to be intimidated by people in positions of power, but always keep at the focus of their mind that individual woman who deserves our best care and the best treatment.

Comm: This is the first time that this story has been made public. Panorama has established help lines for those women who may have been affected by the issues raised in tonight's programme including those who are concerned they may have been put at risk in Bradford.

The help- line numbers - provided by the charities Breakthrough Breast Cancer and Breast Cancer Care are 08080 100 200. That's 08080 100 200.

End Credits



SEE ALSO:
Response to the Lancet
31 Mar 06 |  Panorama
Q&A: Breast Cancer
31 Mar 06 |  Panorama


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