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FULL TRANSCRIPT

   1                   Day 36, 8th July 1999
   2   (9.37 am)
   3   THE CHAIRMAN: Good morning, everyone. Good morning,
   4     Miss Grey.
   5   MISS GREY: Sir, today we have the benefit of hearing from
   6     Dr Baker, who is now of the Avon Health Authority.
   7     Could I ask him to come forward, please?
   8        Good morning, Dr Baker. We have been taking
   9     evidence on oath or affirmation in this Inquiry, so
  10     could I ask you, please, to stand to affirm?
  11           DR IAN ALFRED BAKER (AFFIRMED):
  12             Examined by MISS GREY:
  13   Q. Dr Baker, you have provided a full statement to this
  14     Inquiry already and can I just, on behalf of the Inquiry
  15     team, firstly thank you and your representatives for
  16     that statement? It is extremely full and thorough, and
  17     that will, I am sure, assist us this morning in trying
  18     to manage this hearing by only highlighting those
  19     aspects which would be of particular interest or concern
  20     to the Panel today.
  21        Perhaps we could start by turning that statement
  22     up. It is WIT 74/1. That is the title page. We see
  23     there it is the statement of Dr Baker, consultant in
  24     public health medicine, now at the Avon Health
  25     Authority.

   1        If we turn, please, to page 4, there is the start
   2     of that statement, where we are told, at paragraph 1,
   3     that you were previously of the Bristol & District
   4     Health Authority, where you were first the District
   5     Medical Officer of Bristol & Weston Health Authority and
   6     then, afterwards, when that became the Bristol
   7     & District Health Authority, you took up a variety of
   8     posts but became the District Medical Officer in
   9     particular.
  10        If we could just turn firstly to page 64 of that
  11     statement --
  12   A. I am sorry, could I come in? In fact, when Bristol
  13     & District Health Authority was formed, that is when
  14     I became a consultant in public health medicine, and did
  15     not retain the title of District Medical Officer.
  16   Q. I have been summarising rather quickly to get to the
  17     formal point which is at page 64: is that your signature
  18     which appears at the bottom of the statement?
  19   A. Yes.
  20   Q. Are the contents of the statement true to the best of
  21     your knowledge, information or belief?
  22   A. They are.
  23   Q. If we go back, then, to page 4 of the statement, we see
  24     there in rather more detail the various posts that you
  25     have held with the district and then with Avon in some

   1     rather more detail. If perhaps just again we could turn
   2     to page 67, we see there your curriculum vitae, firstly
   3     details of your qualifications and secondly, if we turn
   4     over the page, page 68, the clinical appointments which
   5     you held within the NHS before turning towards
   6     a planning and public health role?
   7   A. Correct.
   8   Q. Furthermore, if we turn back to page 66, you give there
   9     the details of your appointments and the positions which
  10     you have held within the Bristol & Weston Health
  11     Authority, within the Bristol & District Health
  12     Authority, and within the Avon Area Health Authority?
  13   A. That is correct.
  14   Q. Turning back to page 4 of the statement, please, the
  15     course I propose to adopt, Dr Baker, with your
  16     permission this morning, is to go through your statement
  17     as it were page by page, picking up various documents
  18     and various themes that emerge from the statement, so it
  19     will broadly follow the structure of your evidence in
  20     the statement.
  21        If one starts at paragraph 4, you talk about your
  22     function as an assistant district manager, information,
  23     and the role that you had there in strategic and
  24     operational planning. You mention there the
  25     government's document "Care in Action" which sets out

   1     the government's requirements for priorities in service
   2     planning.
   3        If we could just look at the title page to that
   4     document, it is to be found at WIT 74/79.
   5        If one turns over to page 83, one sees there the
   6     covering letter and at the bottom the fact that the
   7     government said that the main emphasis of their
   8     priorities continues to be along the lines on which
   9     their predecessors were already working.
  10        If you turn to page 84, it is said there that it
  11     included giving a high priority both to the prevention
  12     of ill health and to the so-called "Cinderella" services
  13     for those who were ill or handicapped, and those who
  14     were elderly.
  15        If one turned to the body of the document itself,
  16     one would see at page 123, please, that there was
  17     discussion there of services for children in amongst the
  18     priorities of the government.
  19        Can I ask you, Dr Baker, at that time, looking
  20     back to 1984/85, what was the place and what was the
  21     focus of the policy for services for children within the
  22     overall parameter of policies and planning for the
  23     Health Service?
  24   A. I think it was, indeed, as you have outlined, which in
  25     an earlier paragraph was to be addressed, but also in

   1     the light of a local assessment and local priorities.
   2     From my recall, we addressed preventative and community
   3     care aspects of child health in our planning documents
   4     and addressed other clinical paediatric services in the
   5     light of our local circumstances.
   6        I think, in my own document, where I quote from
   7     Care in Action, there is in fact an error. I have
   8     included three regional priorities for services in the
   9     list of priorities which were in the Care in Action
  10     document in an earlier paragraph that you showed. The
  11     priorities concerning coronary artery bypass services,
  12     renal services and transplant services were indeed
  13     regional priorities for us to address.
  14   Q. So that is a correction to page 4 of your statement?
  15   A. Yes.
  16   Q. If we go back to that, we see there a list of the
  17     services which are said to be the government's
  18     requirements for priorities in service planning. Do
  19     I understand from what you have just said that the last
  20     three on that list should be more properly described as
  21     the "regional priorities" rather than those reflected in
  22     the document we have just seen?
  23   A. Correct.
  24   Q. However, there was a priority in service planning set by
  25     the government for children's health service with,

   1     I think, from the document we have just seen,
   2     a particular focus in planning for community services
   3     for children; is that right?
   4   A. Correct, yes.
   5   Q. If we turn down, perhaps, towards the regional level of
   6     planning, this is something which you address at
   7     paragraph 5 of your statement there. We look, perhaps,
   8     at one of the documents you have referenced there, which
   9     is to be found at WIT 74/145.
  10        This, as you see, is of course the
  11     Bristol & Weston Health Authority's strategy for acute
  12     and related services. Perhaps just again, to refresh
  13     your memory, if we look at pages 146 and 147, one sees
  14     there the overall content of the document and in
  15     particular, the context of the revenue constraints under
  16     which this review was taking place.
  17        Can you tell us what its purpose and its focus
  18     was?
  19   A. Its purpose was to allow the Health Authority to have
  20     a comprehensive view of strategy for services for the
  21     period 1986 to 1994, within which further, more detailed
  22     planning could take place. The arrangement in the 1980s
  23     was for planning to come forward into so-called annual
  24     programmes, which covered the immediate forthcoming year
  25     and the following year, and those programmes took

   1     two-year bites, if you like, from the agreed strategy.
   2        So this strategy allowed the Health Authority an
   3     overview of its forward thinking and planning for that
   4     period. It would have been submitted also to the
   5     Regional Health Authority as an indication to them as to
   6     how we had met national, regional and our local
   7     priorities.
   8   Q. If one takes the sector of acute services as a whole,
   9     what was the general policy aim in relation to that
  10     sector when set against other sectors such as, to take
  11     an obvious contrast, community health services?
  12   A. Because of our resource position as understood at that
  13     stage, it was to cap resource development in acute
  14     services, because of the need to address the priorities
  15     for the so-called "Cinderella" services which you
  16     indicated earlier, and paragraph 1 mentions the strategy
  17     to transfer 7.4 million to the designated priority
  18     services. That had the implication that not only were
  19     acute services capped in a development sense, but they
  20     in fact had to find "cost improvement savings" as the
  21     term was used to help identify that 7.4 million for
  22     developments.
  23        In paragraph 1(d), it mentioned the exception,
  24     which was to exclude neonatal services from the actual
  25     reduction of 5 per cent expenditure, so that service

   1     remained, if you like, in a more steady state.
   2   Q. In fact, it is a little wider than that, is it not,
   3     because if we look at (c), there is a further exemption
   4     mentioned, is there not, and that is cardiac services?
   5   A. Yes, correct. The development of cardiac services
   6     certainly was funded separately by the Regional Health
   7     Authority. There was an arrangement of development
   8     funding for the expansion of cardiac services which
   9     I think only became the funding responsibility of
  10     district health authorities at a later stage. There was
  11     a priming of services for cardiac and presumably for
  12     renal and bone marrow transplant services.
  13   Q. If we could look briefly at page 149 --
  14   THE CHAIRMAN: Miss Grey, may I just go back to that for
  15     a moment, what we were just looking at?
  16   MISS GREY: 147, please.
  17   THE CHAIRMAN: The second sentence in (c), the last two
  18     words, "in children", does that apply only to bone
  19     marrow transplant or to all three services, in your
  20     recollection?
  21   A. Only to bone marrow transplantation.
  22   MISS GREY: If we could turn, then, to 149, that sets out,
  23     if we could turn, please, to 3.2, the exception, is this
  24     right, to the policy that you have already generally
  25     described in that the authority was host to an expansion

   1     of cardiological and cardiac surgical services?
   2   A. Correct.
   3   Q. Can you tell us what your understanding was of the
   4     place of children within that expansion, and perhaps
   5     paragraph 3.2.3 will help.
   6   A. Thank you. The joint planning which was taking place
   7     between representatives of the Regional Health Authority
   8     and the Bristol & Weston Health Authority was focused on
   9     the expansion of open cardiac surgery which required
  10     bypass support to the surgery taking place. That was
  11     deemed to include children as well as adults, but the
  12     region and ourselves were aware that in parallel,
  13     Bristol had been designated a supra-regional centre for
  14     neonatal and infant cardiac services. There was
  15     separate funding for that purpose. So there was
  16     a parallel development, but obviously, there was some
  17     integration required for the expansion of services for
  18     children under 1 to take place at the same time as
  19     expansion of services for children over 1, which was
  20     part of the need for the expansion of open cardiac
  21     surgery.
  22   Q. Did that present a planning challenge from
  23     a co-ordination point of view?
  24   A. Yes, to some extent. I think the advantage of the
  25     direct funding of the supra-regional service in some

   1     senses made that easier. The bulk of the enlargement of
   2     the service was not in that service and I think most of
   3     the effort of the region and ourselves concentrated on
   4     adults and to a small extent the accompanying expansion
   5     of the children over 1.
   6   Q. Can you just tell us what the reasons were for that
   7     concentration of effort by yourselves in the region?
   8   A. It related to the region accepting that in particular,
   9     surgery, operation rates for coronary artery bypass
  10     grafting surgery for adults in the South West was lower
  11     than elsewhere in the country, and it was necessary to
  12     increase the facility in Bristol in order that districts
  13     in the South Western region could increase their adult
  14     cardiac surgery rates.
  15   Q. Because if we look at another document -- this is at
  16     HA(A) 117/24; this is a similar date in that it is
  17     a note of a meeting on 15th October 1985, a discussion
  18     with regional specialties, cardiac surgery. We see
  19     a list of attendees which includes yourself. If one
  20     looks generally through the agenda, if we scroll
  21     through, there is a discussion firstly of the need to
  22     look at matters such as the take-up from different
  23     residents. I am looking at paragraph 3.2.
  24        Then, if we turn over the page, there is
  25     a discussion of the importance of equitable access to

   1     facilities and that was an important strand in planning
   2     over the period, was it not?
   3   A. Correct.
   4   Q. And if we look, then, to the discussion of the present
   5     service, paragraph 7, at the bottom of that, if I could
   6     just ask you to read through that briefly, and turn on
   7     to paragraph 7.2, at the bottom of paragraph 7.2 we see
   8     the statement that:
   9        "Whilst the service for children is adequate, that
  10     for adults is significantly under-provided."
  11        Was that an accurate summary of the perception of
  12     the balance of service provision at the time?
  13   A. Yes, I think it was.
  14   Q. So did that then have an impetus or effect on the
  15     planning priorities and problems that you perceived
  16     yourself to be addressing at the time?
  17   A. Yes.
  18   Q. The statement that "whilst the service for children
  19     is adequate, that for adults is significantly
  20     under-provided", does that relate to the over or
  21     under 1s, or does it relate to both, to the best of your
  22     recollection?
  23   A. I think probably it related to over 1s. It obviously
  24     does not make any differentiation, but I think we were
  25     always clear that for the under 1s there was a service

   1     provided directly by the supra-regional service, albeit
   2     in facilities which were common to the service for the
   3     provision for children over 1.
   4   Q. So from a planning point of view, you were primarily
   5     addressing the over 1s rather than the under 1s; does
   6     that follow?
   7   A. We were. Certainly this mentions the adequacy.
   8     I cannot help you, it could apply to both age groups for
   9     children, it could just be the over 1s.
  10   Q. Since we take the over 1s only, since they were your
  11     planning focus I think we have agreed from 1984 onwards,
  12     did the perception set out in that paragraph change
  13     during the period with which the Inquiry is concerned,
  14     1984 to 1995? If we exclude events at the far end of
  15     that period, in 1995 when specific concerns were raised,
  16     would it be fair to say that generally the perception
  17     was that the service for over 1s was adequate?
  18   A. Yes, that would be correct. I cannot recall, certainly
  19     for the provision of services for children over 1, there
  20     ever being concern about the inadequacy in terms of lack
  21     of capacity of the service provided, and from what I was
  22     aware of, the same view pertained to children under 1 as
  23     well.
  24   Q. When you talk about inadequacy in terms of lack of
  25     capacity, can we just break that down to be clear into

   1     two separate matters? One aspect of the adequacy of the
   2     service is its ability to cater for demands, to process
   3     the number of patients that potentially might be
   4     knocking on its doors. How did the service for the
   5     over 1s fare in those terms?
   6   A. As far as I was able to tell, adequately. The view of
   7     the requirement from the general population of children
   8     was a fairly broad one, that there were estimates of the
   9     frequency of occurrence of cardiac defects and there was
  10     a general view in the Health Service's literature about
  11     the proportion of those children that would require
  12     surgery for their improved survival and avoiding
  13     disability, and that was translated, obviously, by
  14     paediatricians and paediatric cardiac clinicians into
  15     the adequacy of the service that they were giving to
  16     cover that demand. My recall is that I do not think we
  17     ever had an indication from the clinicians that the
  18     service was not covering the demand that came forward.
  19   Q. We will see later specific pressures in particular in
  20     relation to Wales where there were issues around
  21     provision there. But turning away then from the
  22     question of capacity for numbers, what about in terms of
  23     clinical performance or adequacy of standards?
  24   A. I think one of the problems, certainly in the early part
  25     of the Inquiry period, was having any agreed view as to

   1     what the content of the cardiological or cardiac
   2     surgical services, in particular the latter, should
   3     actually be. The service appeared to develop very
   4     rapidly from a very small service at the beginning of
   5     the period in the early 1980s, where a limited number of
   6     procedures were carried out against obviously the same
   7     prevalence of cardiac defects in the population, some of
   8     which have a high mortality on their own, actually, and
   9     then it proceeded rapidly to enlarge the number of
  10     approaches in both cardiac surgery and cardiology to
  11     deal with an increasing range of defects.
  12        So in some senses, one had to judge adequacy of
  13     the service by the adequacy of the service in
  14     a designated centre and for over 1s to allow clinicians
  15     to develop the service.
  16        I suppose the stark contrast was with adult
  17     cardiac surgery, where there was a much more clear view
  18     as to where the deficit lay, and that was essentially
  19     the one procedure, which was coronary artery bypass
  20     grafting for adults, and where one had a view of the
  21     target and how it could develop. One did not have that
  22     same view for children --
  23   Q. I am sorry to interrupt you there. May I clarify, when
  24     you talk about coronary artery bypass grafting as being
  25     the one area in which there was a deficit, are you

   1     talking there about the numbers of grafts needed or are
   2     you talking there about an issue over the standards
   3     being attained at the BRI in performing those
   4     procedures?
   5   A. I am talking about adequacy by volume.
   6   Q. Thank you, I thought so.
   7   A. I think the point I am making about children and
   8     adequacy by service standard is that it was a service
   9     undergoing its own rapid development as clinicians felt
  10     able to tackle a wider range of defects during this time
  11     period. I do not think we had an easy view of
  12     standards from that point of view. If you like, the
  13     standard was the ability of a cardiac centre, both for
  14     over 1 children and under 1 children, to address the
  15     demand of a wide range of defects.
  16   Q. But that would appear to mean that the standard was
  17     related only to throughput rather than to the quality of
  18     output?
  19   A. I think to some extent that was the case. I think
  20     obviously there would be clinical concerns about the
  21     quality of the service. I was not aware that there was
  22     an expression from any NHS source, nationally or
  23     regionally, or in fact professional sources, about the
  24     standards of the surgery for children being performed.
  25   Q. Would you like just to take it? We will come back to it

   1     in further detail. Was there a point at which you
   2     became aware that there were concerns being expressed
   3     about the quality of clinical performance?
   4   A. I became aware of that certainly in 1995 when reports
   5     became available to me. I was aware of the fact that
   6     the supra-regional service was advised by an advisory
   7     group of clinicians, and I had possession of an interim
   8     report of an assessment of the designated centres in,
   9     I think 1988.
  10   Q. In 1989. You have given us a reference for it.
  11   A. That is right. I subsequently had, indirectly, advice
  12     from an assessment made by the Royal College of
  13     Physicians Working Group when they were ascertaining the
  14     need for the service in Wales and in Bristol, which
  15     I believe involved some clinical judgment of the quality
  16     of service, but I did not see that report directly;
  17     I only was aware of the eventual outcome as it affected
  18     services in Wales and in Bristol.
  19   Q. I think you refer later in your evidence to having seen
  20     extracts from it. Would that be accurate?
  21   A. Yes.
  22   Q. Does it follow from your earlier answer, when you talked
  23     about throughput as being a measure of standards, that
  24     the view might have been taken that if a centre was
  25     being designated as a centre for expansion, if all the

   1     pressures on it were for expansion, and if no concerns
   2     that at least you were aware of were being expressed as
   3     to clinical outcomes or performance, that that became an
   4     adequate measure or proxy for satisfactory performance?
   5   A. Yes. That is my answer: yes.
   6   Q. If we go back to where we started on this topic, because
   7     I have taken you a little bit out of turn, this was
   8     a planning document on planning for expansion in cardiac
   9     services, and I think you have told us throughout your
  10     statement that that was a major theme of the activities
  11     of the Regional Health Authority, the South West
  12     Regional Health Authority, and therefore also of the
  13     district in its implementing and planning function?
  14   A. Correct.
  15   Q. Another aspect of the priorities at the time were, of
  16     course, services for children. Perhaps we could just go
  17     back, please, to the same document as we were previously
  18     looking at, the district planning document, WIT 74/162,
  19     please.
  20        This is the plan for children's services and it
  21     sets out the various sectors: community, hospital-based
  22     paediatric services and other hospital based services
  23     which treat children.
  24        The relevant pages continue to page 166. I will
  25     not ask us to look at them all at this stage, but is it

   1     right that the provision of neonatal care and neonatal
   2     intensive care in particular posed a particular
   3     challenge for the district in planning terms throughout
   4     this period?
   5   A. Correct, yes.
   6   Q. Can you just help us briefly as to why that should be
   7     so?
   8   A. I think it was a rapidly developing subspecialty of
   9     children's services and the intensive care aspect of it
  10     was also a very expensive aspect of service provision,
  11     so that in the financial and planning framework in which
  12     we were working, to meet the pressures from clinicians
  13     to develop that service was quite difficult at the rate
  14     at which they would like to see it develop.
  15        Then I think, in addition, there were also
  16     staffing issues with regard to the speed with which the
  17     intensive care cots could be actually staffed in the
  18     period as well.
  19   Q. If we could just briefly go through a few documents
  20     relating to this: could we have a look at HA(A) 29/158?
  21        That sets out information to you that the South
  22     West Regional Health Authority were proposing to review
  23     neonatal intensive care and neonatal services in the
  24     various health districts and that was a review that then
  25     went on to take place, did it not?

   1   A. Yes.
   2   Q. Can we go on to UBHT 266/9? This was a letter from
   3     Professor Dunn. We can see it at the next page,
   4     page 11. At that time Professor Dunn was the Reader in
   5     Child Health and Perinatal Medicine; subsequently he
   6     became Professor.
   7        If we go back to page 9, the first page of that
   8     letter, if you scroll through that letter very briefly,
   9     is that a letter you have seen before, Dr Baker?
  10   A. Presumably, but not for a long time.
  11   Q. I think I might fairly summarise it as being a heartfelt
  12     plea for further resources in the neonatal intensive
  13     care field in particular and the pressures that were
  14     being put upon the service that Peter Dunn was
  15     attempting to provide by in particular care for non-Avon
  16     babies.
  17        Again, for the sake of the record, there is
  18     a response to this letter at UBHT 266/5 to Dr Roylance,
  19     where the position in defence of the funding
  20     arrangements made is set out.
  21        But the question that I wish to ask you, Dr Baker,
  22     is this: if one looks at the issue of funding for
  23     children's services broadly and concentrates not merely
  24     on cardiac services, would it be fair to say that there
  25     were pressures upon the services, those services really

   1     in the hospitals, as a result of some of the same trends
   2     as we see in cardiac services, namely, the move towards
   3     treating children at a younger age and therefore the
   4     greater requirements of specialisation and care that
   5     were imposed upon services by that trend?
   6   A. Yes. I think very much so. I think one of the planning
   7     issues for the district at that time was the emergence
   8     of subspecialties in children's care, and to some
   9     extent, the -- competition may not be the right word,
  10     but competition for facilities and staff to give general
  11     paediatric services or specialised paediatric
  12     services -- I think it was a crossroads in the
  13     development of children's services, and Bristol and its
  14     Children's Hospital, being teaching hospitals, was very
  15     much active at that crossroads.
  16        So I think it presented a planning and
  17     professional debate which was quite active.
  18        I think the other thing that these letters reflect
  19     as well, which was very commonplace, was to some extent
  20     from a planning and public health point of view, the
  21     challenge within a teaching district of meeting the
  22     expectations of very progressive and clever clinicians
  23     to advance their services, whilst at the same time
  24     trying to ensure some balance of care which represented
  25     good standard NHS care.

   1        Obviously, we wished that they were not in
   2     conflict, but the expectations were such sometimes that
   3     they were.
   4   Q. In the field of child health, was there a conflict at
   5     times between developing a community of child Health
   6     Service and putting money into acute services within
   7     hospitals?
   8   A. There could have been. I cannot specifically remember
   9     instances. I think my memory tends to remind me that it
  10     was more by way of a debate about the maintenance of
  11     general paediatric services, hospital-based, as opposed
  12     to specialised children's services, hospital-based, of
  13     which neonatal intensive care and neonatal and infant
  14     cardiac surgery will be examples.
  15   Q. Did the fact that there was an ongoing debate or issue
  16     as to the adequacy of the provision of neonatal
  17     intensive care and children's services more generally at
  18     the Bristol Maternity Hospital, the BMH, St Michael's,
  19     and the Children's Hospital, have any impact in 1984 to
  20     1991 on the other issue of whether children's services
  21     within cardiac surgery should be integrated into
  22     children's services at the Children's Hospital?
  23   A. I think there were several expressions of paediatric
  24     advice, clinical advice, that it would be preferable
  25     that all children's services, including children's

   1     cardiac surgical services which took place at the BRI,
   2     be integrated together, and I think that advice was
   3     available early in the period and was addressed
   4     progressively in different aspects throughout the
   5     period.
   6        I think that in a way one might consider that that
   7     added to the competition for space and facilities and
   8     staff at the Children's Hospital.
   9        Some part of our planning documents, possibly the
  10     ones you have alluded to already, indicate I think an
  11     early view that the facility of the Royal Hospital for
  12     Sick Children would have to be redeveloped and I think
  13     that was in terms of modernisation and allowing the
  14     opportunity for the development of subspecialties. That
  15     was another planning issue in its own right. I think
  16     all these elements were active together at the same
  17     time.
  18   Q. If we could go back, please, to your statement at page 5
  19     this time, WIT 74/5, you carry on discussing your
  20     contributions to planning throughout this period, and
  21     also, again by reference to documents, the broad thrusts
  22     of the concerns and policy priorities of the district at
  23     the time.
  24        Just at paragraph 7, you talk about the planning
  25     requirements and the resources available after 1991 when

   1     you talk of Mr Parr advising that the new weighted
   2     capitation would mean the Bristol & Weston Health
   3     Authority could expect no real resources for the period
   4     1991 to 1995 and that service development would have to
   5     be achieved through cost improvements.
   6        As it stands that paragraph appears to imply that
   7     funding had been more generous before 1991. Would that
   8     be accurate?
   9   A. I do not think so, but I have no facts. I think the
  10     earlier documents expressed a similar view of tight
  11     resources, whereby it was through cost improvement
  12     within services that resources became freed up for
  13     development. Obviously, there were exceptions to that
  14     and obviously neonatal and infant cardiac surgery and
  15     the direct funding was an exception, but in the main,
  16     for the bulk of services, my recall was that through
  17     most of the period of the Inquiry, we had very little by
  18     way of free new monies to develop services with.
  19   Q. If we could just go on through your statement, please,
  20     I think that we will take it as read until we come,
  21     please, to page 8, where you set out, at paragraph 15,
  22     the involvement which you had in auditing or examining
  23     the performance of the UBHT's adult cardiac surgical
  24     services and the services of individual surgeons in
  25     1996. You make the point, of course, that you had given

   1     a very brief summary of these matters since they lie
   2     outside the Inquiry's terms of reference and period of
   3     investigation.
   4        However, I would, if I may, take you to a few
   5     documents, because they illustrate, perhaps, that some
   6     of the issues that you were looking at were perhaps
   7     common to both adult and children's services.
   8        If one looks at HA(A) 125/22, is this right: this
   9     is your audit, as it were, of clinical standards for
  10     cardiac surgery in adults?
  11   A. Correct.
  12   Q. And this was undertaken by you in 1996?
  13   A. Correct.
  14   Q. If we just go on, please, through that document and turn
  15     over the page, please, you have set out your approach
  16     and you then talk about the limits of tolerance for the
  17     data.
  18        You set out, at the bottom there, that the
  19     surgeons of the UBHT have collected and collated data on
  20     CABG surgery but do not appear to have conducted
  21     rigorous audit in the sense of setting standards
  22     prospectively, monitoring and reviewing data in relation
  23     to standards and considering any necessary changes in
  24     practice.
  25        The last sentence:

   1        "There has been no process of formal and
   2     systematic validation of the data."
   3        Would you have any knowledge of whether those
   4     comments could be applied to paediatric cardiac surgery,
   5     or not?
   6   A. I think if we take the last point first, the formal and
   7     systematic validation of data, obviously that needs to
   8     underpin any approach to audit. I will say from the
   9     point of view of this audit carried out, if you like,
  10     under my auspices, I was not able to undertake that, but
  11     I suppose I am just making the point that audit carried
  12     out by clinicians, it requires that validation of the
  13     data. That is obviously important.
  14        With regard to approaches otherwise, I think the
  15     explicitness of standards in audit was frequently
  16     a problem, most often because they were indeed absent
  17     and that reference to any national or professional
  18     standard to use being agreed upon was not present. But
  19     nevertheless, the concept of audit did require the
  20     setting of a standard, so even in the absence of
  21     a standard, audit could not be really fully conducted
  22     unless a standard was set and you compared your position
  23     on analysis with the standard you had set for yourself
  24     within your own service.
  25        That standard could obviously be adjusted if other

   1     evidence or national guidance became available.
   2        In this case, in adult surgery, as I state here,
   3     there seemed to be no specific standard. I think that
   4     what I cannot comment on directly is, there was, year on
   5     year appraisal of the adult cardiac surgery outcomes and
   6     it may well be that the clinicians felt that in so
   7     doing, they were observing that their services were not
   8     deteriorating, so implicitly they might have been
   9     considering standards.
  10        You asked me about children's services. I think
  11     the setting of standards, as I understand it there, was
  12     even more challenging.
  13   Q. We will come to a few letters bearing on that in
  14     a moment. For the moment, if we could just turn on to
  15     page 24, you there go on to discuss the conclusions, if
  16     we can just go down a little, please. You carry on
  17     there by making the point that it is very difficult to
  18     compare the results with standards or outcomes in other
  19     institutions. Would that be a conclusion that you would
  20     consider would be a problem in paediatric cardiac
  21     surgery as well?
  22   A. Very much so, yes.
  23   Q. If we go on to some of the letters that you wrote on
  24     this subject, there is a letter at page 403, please, of
  25     your statement, to the Secretary of the British

   1     Cardiothoracic Society. This is a letter from yourself,
   2     if we could just scroll down, please.
   3        You set out there a series of questions, that in
   4     particular, you would be grateful to learn "if your
   5     society [the Society of Cardiothoracic Surgeons] has
   6     advice with regard to your own benchmarks or variation
   7     in operative mortality by procedure by surgeon against
   8     either professionally set norms or expectations from
   9     your national overview."
  10        Then further questions are set out in the next
  11     paragraph. If we go over the page, the questions are
  12     relating primarily then to adults?
  13   A. Yes.
  14   Q. Are these the concerns that arose out of your audit, or
  15     your attempts to undertake audit in adult patients?
  16   A. Yes.
  17   Q. If we go on, then, please, to page 405, you are
  18     essentially given at that stage a fairly limited
  19     response.
  20        If we go on, please, to page 406, was this
  21     correspondence picked up any further, or did the matter
  22     get resolved more satisfactorily in any way?
  23   A. I think, from memory, I did have a telephone
  24     conversation with the person Brian Keogh referred to in
  25     the previous letter, and I think he advised me that he

   1     was working on the matter, but there was no expectation
   2     of early results.
   3   Q. I think it may be that if we went through to HA(A)
   4     123/55, you will see a further discussion of this
   5     matter.
   6   A. Yes, I had the opportunity to meet Professor de Buono at
   7     a meeting and shared with him some of the concerns in
   8     the area. I think I sent him a copy of the report and
   9     I think at the time he said it was certainly an area
  10     that cardiologists were very concerned with and were
  11     working on, again, in this area.
  12   Q. Perhaps to complete the sequence we should turn back to
  13      page 31, where you are again enquiring as to what
  14     standards there are. If we turn over the page, I think
  15     we will see your signature at the end of this letter;
  16     is that right?
  17   A. Yes. I was a member of the Royal College's Audit
  18     Working Group, and Dr Hopkins was the Chair of that
  19     group. It was an opportunity to try and share the
  20     complexities I found myself in with him.
  21   Q. Then, just for the sequence, page 48, the response,
  22     where you are referred on to Professor de Buono.
  23        Page 49, please. This is your letter to Professor
  24     de Buono that we have seen. Then page 55, please. There
  25     the database is again referred to.

   1        So the upshot of your involvement, both in adult
   2     and indeed in paediatric cardiac surgical standards in
   3     terms of audit from 1995 onwards was that you made
   4     fairly extensive enquiries as to what national standards
   5     or standard setting processes were being developed
   6     within the UK?
   7   A. Yes, correct. The focus of my work was around adult
   8     cardiac care, the largest volume of surgical activity
   9     was with regard to that care, and it was in that light
  10     that I followed this through.
  11   Q. Then, again, if one looked at WIT 74/400, we see there,
  12     do we not, the letter that you mention in your statement
  13     to Mr Wisheart that you wrote to him pending his
  14     appearance before the General Medical Council in which
  15     you set out, is it fair to say, the problems in standard
  16     setting as you perceived them in the field of cardiac
  17     surgery?
  18   A. Correct.
  19   Q. What was the purpose of that letter?
  20   A. It was one of support to Mr Wisheart. He had been
  21     a long-standing professional colleague and I wished to
  22     give him this view of how I saw surgery at that time --
  23     cardiac surgery.
  24   Q. Thank you. It may be a convenient moment to have
  25     a break, if we could perhaps break for a quarter of an

   1     hour, Chairman?
   2   THE CHAIRMAN: Yes, of course. We will reconvene at 10 to
   3     11.
   4   (10.34 am)
   5               (A short break)
   6   (10.55 am)
   7   MISS GREY: Dr Baker, I wonder if we could turn to page 9 of
   8     your statement.
   9        If you look at paragraphs 1 to 3 of the services
  10     offered at the BRI and the Children's Hospital, just
  11     a small point here, but if we look at page 3, you talk
  12     there of catheter sessions for children being provided
  13     at the Children's Hospital from 1987.
  14        If we could just look also now at page 75 of your
  15     statement, this is where the general statement on behalf
  16     of Avon Health Authority in relation to the split site
  17     issue has been filed.
  18        If we look at paragraph 2.5, we see there that the
  19     Children's Hospital part of the development was
  20     completed in 1986, so on its face, there might appear to
  21     be a conflict between the two. It is right to say that
  22     the Trust has submitted a comment on the statement to
  23     say that the Trust's records show that the development
  24     of the catheter laboratory facilities at the Children's
  25     Hospital was completed in April 1987 rather than in

   1     1986.
   2        Is that something you would like to come back on?
   3   A. Thank you. I think one problem is that the so-called
   4     opening of the facility did have several different
   5     facets. I think certainly, my documents informed me
   6     that when I wrote a report in February 1987, the use for
   7     patients of the catheter facility was imminent in
   8     February 1987. So I think that is compatible with the
   9     Trust's advice that it was in use by April 1987.
  10     I think there was a long lead time to the planning and
  11     tendering and building process.
  12   Q. There may be a difference between some aspects of work
  13     being completed and commissioning of the services and
  14     getting it up and running?
  15   A. Correct.
  16   Q. If we go back, please, to page 9 of your statement, to
  17     a different part of it, at the bottom, when you talk
  18     about funding of services and the incentives created
  19     thereby, at the last paragraph, paragraph 2, you talk
  20     about the funding of supra-regional services for
  21     neonates and infants by the Department of Health
  22     probably acting as an incentive towards switching the
  23     workload of paediatric cardiac surgery to children in
  24     this age group from older age groups.
  25        Are you aware, Dr Baker, of a trend in clinical

   1     matters during the period of the Inquiry whereby
   2     children were operated upon at increasingly earlier
   3     stages because of a clinical perception that that was
   4     better for their best interests?
   5   A. Yes, I was. That is certainly true and I am sure was
   6     the prime driver to the change in age group for
   7     surgery. I suppose what I am reflecting here is maybe
   8     that there was no financial constraint. The section
   9     asks for incentives created thereby, and I suppose I was
  10     stretching that to see that the lack of constraints for
  11     funding could have acted as an incentive. But you are
  12     right to say that the clinical trend was present
  13     already.
  14   Q. If we were to ask the clinicians who were providing the
  15     service about this point, they might well say that the
  16     judgments made as to the time of intervention were based
  17     purely upon the clinical needs of the child and were not
  18     influenced by any form of financial incentive.
  19        Would you be in any position to comment on that,
  20     or to separate out, as it were, the effect of the lack
  21     of funding constraint upon the clinical judgment or
  22     assessment?
  23   A. I would agree with your view, and I indicated earlier
  24     this morning that I was not aware throughout the period
  25     of any constraint on the capacity of services for

   1     children over 1 either, so in both senses, there was no
   2     constraint on clinical activity.
   3        I agree with you entirely that that would be the
   4     prime mover. We did, on occasions, run into some
   5     problems of interpretation of how to consider the
   6     service for a child who was in transition between
   7     under 1 and over 1, perhaps in the course of
   8     investigations or care, but I think probably financial
   9     directors found ways to cope with that.
  10   Q. It is just that looking at the matter from the outside,
  11     as it were, it might be thought that it would be
  12     difficult to test either of the two potentially rival
  13     assertions that, on the one hand the decision was at
  14     least influenced by funding mechanisms; on the other,
  15     that it was not so influenced but was dictated only by
  16     clinical need, if both were incentives driving in the
  17     same direction?
  18   A. I absolutely agree, but I have no hesitation in thinking
  19     that the prime determinant of care would be clinical
  20     decisions.
  21   Q. Thank you. If we could turn over the page, please,
  22     to page 10, you describe there organisation setups and
  23     lines of authority and so on. You refer us to a number
  24     of documents relating to the structure of the district
  25     and its various components as arranged in 1985.

   1        Looking at paragraph 2, you describe there the
   2     advent of district general management and if we could
   3     look briefly, please, at the document referred to there,
   4     it is WIT 74/424.
   5        It is in fact a paper written by Dr Roylance.
   6     That appears from page 428, but I do not think we need
   7     to turn it up. It forms a paper addressing the
   8     proposals that are made to the Regional Health Authority
   9     on the introduction of general management.
  10        If we scroll down to "Aims", we see the aims of
  11     the proposed changes and in particular the fact that
  12     they are intended to address major problems facing the
  13     authority which include:
  14        "(c) chief maximum delegation of responsibility
  15     and authority to operational level within the policy set
  16     at district level;
  17        "(d) to provide greater involvement of the
  18     operational level in formulation of policy at district
  19     level."
  20        Dr Baker, you have described in your statement the
  21     changes both in 1985 and also in 1991, and we have heard
  22     in general about the fact that the formation of, say,
  23     the clinical directorates in around 1991 as part and
  24     parcel of the creation of Trust status was intended at
  25     least in part to devolve authority for decision-making

   1     closer to the patient's bedside.
   2        Would it be fair to look at this document and to
   3     say that that was a trend, a trend of devolution or
   4     downwards delegation, that had already started in 1985?
   5   A. Yes. I would agree with that.
   6   Q. Did the restructuring that is described in this document
   7     make any real difference, however, to the level at which
   8     decision-making took place?
   9   A. I think it allowed the opportunities to occur which are
  10     set out in these aims. I think it was the combination
  11     of having a district level policy and that was
  12     interpreted into the strategies that we mentioned
  13     earlier this morning, and that within those strategies
  14     there was the creation of what I have called
  15     "capacities" within which clinical services took place.
  16        So that allowed for priorities and resource
  17     boundaries, et cetera, to be active, but that having
  18     been set, there was maximum clinical freedom to provide
  19     the service.
  20        Then I think (d) is trying to capture the fact
  21     that, appropriately, the development of the policy and
  22     the strategies had to take into account the view of
  23     clinicians and others who were active at the operational
  24     level.
  25        I can recall that great effort was made to do that

   1     in Bristol & Weston. Clinical Directors actively met us
   2     as planners, and members of the authority who were
   3     involved in planning, to give us their views.
   4   Q. There you mentioned Clinical Directors. I think that
   5     would have been from 1991 onwards?
   6   A. I am sorry.
   7   Q. You say in fact in your statement at page 11, and I am
   8     simply quoting, medical staff were involved directly in
   9     management of services through the structure of clinical
  10     divisions from 1985 onwards. Is that accurate? Were
  11     doctors involved in the management of services from 1985
  12     onwards?
  13   A. Yes. I think "management" needs a broad interpretation
  14     there. The heads of the clinical divisions were
  15     influential both upwards in the policy and strategy
  16     debate and downwards in the development and performance
  17     of services.
  18   Q. If we turn over the page, however, the existing
  19     document -- so we are looking at page 425 -- we see
  20     there firstly the philosophy of the changes in general
  21     management and also, to some extent at least, at
  22     paragraph 3.5 the dangers or difficulties in managing
  23     change in so far as they have regenerated apprehension
  24     and security in senior middle managers.
  25        However, the general theme in this document -- if

   1     we turn a little further down the page we should see it,
   2     if we turn over the page and turn down to the bottom,
   3     please, to the subject of "Professional Advice", at the
   4     bottom, paragraph 6.3, there is a statement there that
   5     "Care will be needed to avoid confusion between
   6     advisory roles and managerial accountability" when
   7     dealing with the subject of professional advice.
   8        Would doctors' roles within the Health Authority,
   9     within the District at that time, 1985 to 1991, have
  10     been seen as being advisory rather than managerial?
  11   A. Yes, I think so. I think that would be the correct
  12     interpretation, but the availability of advice was
  13     prominent and heads of clinical divisions had very
  14     direct access to the executive officers and to members
  15     of planning committees -- Health Authority members in
  16     planning committees.
  17   Q. So what difference did you see being made by the
  18     introduction of clinical directorates in 1991 in terms
  19     of the involvement of senior clinicians in planning and
  20     management? Was it a major change or a difference of
  21     degree?
  22   A. I would call it a difference of degree.
  23   Q. If we could just go back, please, to page 425, we looked
  24     briefly at paragraph 3.5, where there was talk of
  25     apprehension and insecurity in senior and middle

   1     managers which had communicated itself towards staff,
   2     and there was a need for short timescales for
   3     implementation of these changes.
   4        Can you tell us what the prevailing mood amongst
   5     managers, planners, within the District at that time
   6     was?
   7   A. I am afraid not very easily. I think I can recall my
   8     own view and position; I do not think I can say anything
   9     specific about other managers, I am afraid.
  10   Q. Perhaps you can help us as to your own position, because
  11     the general theme of this is that it was a time of
  12     insecurity because of change. Was that something that
  13     affected you at all, or were you reasonably secure
  14     throughout?
  15   A. I think I felt reasonably secure throughout,
  16     fortunately.
  17   Q. When the document talks about the short time-scales
  18     proposed for implementation, was the District in fact
  19     successful in implementing these changes in reasonably
  20     short order, or did the period of change extend for
  21     a more prolonged period?
  22   A. I think it was reasonably successful. I think that
  23     John Roylance was a reassuring District General Manager
  24     of long-standing within the District, and I think that
  25     helped where other senior managers may have required

   1     support.
   2   Q. If we could go on, then, please, over the page, to
   3     page 11, you talk about, at the bottom, the system of
   4     management -- I am looking at paragraph 4 -- the
   5     involvement of doctors. The system of management was
   6     conceived to give doctors lead responsibilities with
   7     backup from those with general management experience and
   8     skills and that the system was headed by Mr John
   9     Roylance -- Dr Roylance -- who was himself a doctor.
  10        What difference, what importance, would you attach
  11     to Dr Roylance's professional qualifications as
  12     a doctor?
  13   A. I think that this concept which I am describing here
  14     was to give doctors the prime position and to allow the
  15     development of a partnership with managers, but I think
  16     it was never intended to be the other way round and
  17     I think it was always that Dr Roylance himself saw
  18     himself as a doctor and felt it was appropriate to lead
  19     health care, health services, provision as a doctor, to
  20     accept the general management challenge and position,
  21     and I think he viewed doctors as being in a similar
  22     position when it came to clinical divisions and
  23     directorates.
  24   Q. If one looks at the top of your statement, however,
  25     at this page, we see there that actually you are making

   1     it a little more sophisticated, if I may use that term,
   2     in the description there, because you yourself are, of
   3     course, a doctor and so is Dr Roylance, but you describe
   4     a difference in approach there in the focus of your two
   5     respective professional roles?
   6   A. Yes. I think it reflected certainly the background.
   7     Dr Roylance was a clinical radiologist. I had for not
   8     very long been a clinician, my background was in public
   9     health medicine, so my view of health care was very
  10     broad-based in general and Dr Roylance's tended to be
  11     more towards existing patient services. So I think in
  12     some ways you could see the approaches as complementary.
  13   Q. If we could go on to page 12 of your statement you
  14     describe there comments upon the staffing of the Royal
  15     Infirmary and the Children's Hospital, and you make the
  16     point that you yourself had little direct involvement,
  17     other than what was discussed as part and parcel of
  18     various planning documents or activities on behalf of
  19     the South West Regional Health Authority or
  20     Bristol & Weston Health Authority project team, and the
  21     reference there, at paragraph 1, is to a document
  22     JDW 1/175.
  23        It is the third report of the Open Cardiac Surgery
  24     Working Party dated 1984, and we will not go through it
  25     in detail; it does set out the history of this

   1     particular aspect of the region's planning activity, but
   2     if we turn to page 186, there is a discussion there of
   3     the risks of ferrying paediatric cases, if we could
   4     scroll that up, please, where you see there that the
   5     point is being made that if children, very young
   6     children, very often critically ill, have to be
   7     transferred from the Children's Hospital to the Bristol
   8     Royal Infirmary every time a catheter is needed, that
   9     might potentially place them at risk.
  10        This document is dated 1984. It was at a time
  11     when the plan was being developed to move the catheter
  12     facilities to the Children's Hospital, but can I ask
  13     you, Dr Baker, was there a discussion at any time of
  14     whether or not a similar point might not have been made
  15     about open heart surgery, and the dangers to children's
  16     lives that might be posed by transfer to the BRI for
  17     that purpose?
  18   A. I can certainly recall advice in general, that it was
  19     desirable to concentrate all children's services
  20     together. I think that was common advice from
  21     paediatricians and all sorts in the planning process.
  22     I cannot specifically recall any claim that children
  23     were being put at risk having open heart surgery
  24     separately at the Royal Infirmary.
  25   Q. We have already looked at one paragraph of it, but

   1     the Health Authority has already provided a separate
   2     statement dealing with the split site issue. I think we
   3     have agreed that that would be considered in detail or
   4     addressed in evidence by another representative of the
   5     Health Authority, or possibly by yourself, but at
   6     a later date.
   7        If one turns back to your statement at page 12,
   8     you set out the process by which medical staff were
   9     appointed -- I am looking at "Consultants" towards the
  10     bottom of the page. You say there was a requirement to
  11     gain manpower approval for any new consultant
  12     appointments and that the approval was granted in the
  13     first instance -- if you turn over the page, please --
  14     to the Regional Manpower Committee, and then ultimately
  15     to the Department of Health, or the Department of Health
  16     and Social Security as it then was.
  17        So prior to 1991, do we have a system that was
  18     relatively centralised in the procedure that had to be
  19     followed if new appointments were to be made?
  20   A. Yes, that is correct.
  21   Q. You have given us a number of document references
  22     there which I think we will not turn up, but what we
  23     would find is that throughout the first half of the
  24     period we are dealing with, up to 1991, there were
  25     approved first of all posts in paediatric cardiology

   1     that ultimately led to the appointment of Dr Martin at
   2     the Children's Hospital, and secondly, the appointment
   3     of a third cardiac surgeon, which ultimately led to the
   4     appointment of Mr Dhasmana in 1986?
   5   A. Correct.
   6   Q. If we go on, please, to page 14, you deal there with
   7     the training and experience of consultants and in
   8     particular, you mention that consultants were entitled
   9     to 30 days of study leave over a three-year period.
  10        Dr Baker, do you know if those 30 days were
  11     generally used by consultants?
  12   A. My memory tells me that in general, they were
  13     under-used.
  14   Q. If they were under-used, why was that?
  15   A. I do not know specifically. There was the opportunity
  16     to take also professional leave, which covered
  17     consultants undertaking responsibilities with regard to
  18     their Royal Colleges for examination, for committees of
  19     colleges, for advice from the Department of Health,
  20     et cetera. Many consultants in Bristol, from the
  21     teaching hospital, were involved in those activities.
  22   Q. So you are saying that that was a separate form of
  23     leave --
  24   A. Correct.
  25   Q. -- which would not be counted as study leave --

   1   A. Correct.
   2   Q. -- but might nonetheless involve some participation in
   3     professional duties?
   4   A. Certainly, and consume time because of that.
   5   Q. And any other forms of alternative professional duties
   6     or involvement -- I am thinking of the special trustees
   7     and whether they had any influence?
   8   A. I am sorry, with regard to leave, because of the
   9     existence of the special trustees and their resources,
  10     they did support sabbatical leave which some
  11     consultants, not in great numbers, took. This was most
  12     often where there was a request for a period of focused
  13     leave, often visiting other centres, particularly in
  14     North America, for experience purposes.
  15   Q. So those are two forms of leave for professional duties
  16     that would not count formally as study leave, but if one
  17     took those into account, would it be your impression
  18     that the entitlement to study leave or other forms of
  19     professional absence was fully used, or not?
  20   A. I think it was fully used. I was never aware that any
  21     consultant felt inhibited in acquiring the leave,
  22     absence from clinical services. I recall that one of my
  23     concerns as District Medical Officer, alongside the
  24     Medical Staffing Department, was to ensure that there
  25     was adequate cover to cover leave. I think we

   1     concentrated adequately on that and that was ensured,
   2     but as I say, I do not remember there being complaints
   3     of any sort or expressions of concern that there was an
   4     inadequacy of study leave opportunity.
   5   Q. That is an inadequacy or otherwise of study leave
   6     opportunity, but what about taking it in practice? Were
   7     there factors which might make it difficult to take?
   8   A. I do not think so. Nearly all, if not all, consultants
   9     in the District worked extremely hard clinically. I am
  10     sure that would have acted in some ways as a constraint
  11     on taking study leave, but again, I was not aware that
  12     there was any expression of the volume of work
  13     preventing study leave that was thought to be necessary.
  14   Q. Just so that I understand the tenor of what you have
  15     given in evidence, you started by saying that your
  16     impression was that study leave as such at any rate was
  17     not fully taken, but you went on to explore other forms
  18     of leave of absence which might in broad terms be
  19     considered aspects either of professional duties or
  20     education.
  21        Is the overall evidence, therefore, that the
  22     entitlement to time for professional education was fully
  23     used, or not?
  24   A. Fully used.
  25   Q. Was there any guidance or expectation from the District

   1     or yourself as District Medical Officer of how the time
   2     should be used by consultants?
   3   A. No. It was only by exception that occasionally my
   4     attention might be drawn to a claim for study leave
   5     which seemed to be stretching the purpose of study leave
   6     beyond expectations of medical training and if that was
   7     the case, that was discussed, but that was exceptional.
   8   Q. So it follows, therefore, that the District did not see
   9     its role as setting standards or guidelines for forms of
  10     study leave, whether they took the form of reading,
  11     attending conferences, attending other centres or other
  12     forms of retraining?
  13   A. This is correct. It was seen as a clinical matter. We
  14     were in a sense concerned with the bureaucracy and a few
  15     checks on its use.
  16   Q. Is that something which has changed now, or does that
  17     still remain the case?
  18   A. I cannot say. I think since the advent of Trusts in
  19     1991 -- I cannot comment; I do not know.
  20   Q. If we go on, please, to page 16 of your statement, you
  21     describe there patterns of deployment and you comment in
  22     particular that in the early years of the period under
  23     Inquiry, it was common for cardiac consultants to cover
  24     the requirements of both children and adults.
  25        Is that a comment based on your experience of the

   1     facilities at Bristol, or is that a more general comment
   2     relating to the position in the UK?
   3   A. I am afraid I cannot really say. It certainly applied
   4     obviously to Bristol and I think I had a little
   5     knowledge of arrangements elsewhere, but I could not,
   6     with any accuracy, talk about the national scene.
   7   Q. Then afterwards you go on to mention the appointments
   8     that were made during the period of our Inquiry. In
   9     particular, you mention there something we have already
  10     touched upon, the appointment of Dr Martin as
  11     a specialist paediatric cardiologist, and then
  12     Dr Dhasmana as an adult and children's cardiac surgeon.
  13        If we go on, please, to page 17, the statement
  14     here turns to regulatory and disciplinary structures,
  15     issue B1g. Talking of the period before 1991, you say
  16     that your particular responsibility lay with regulatory
  17     and disciplinary structures for medical staff, and you
  18     talk about some involvement in a tribunal which did not
  19     deal with any issues relating to paediatric cardiac
  20     services as such, but you then say in the period 1985 to
  21     1991 you shared responsibilities for regulatory and
  22     disciplinary structures for medical staff with the
  23     Chairman of the Hospital Medical Committee.
  24        Can you help us on the nature of your
  25     responsibilities, Dr Baker?

   1   A. Yes. If potential misconduct or other issues come to my
   2     attention, or the attention of the chairmen of the
   3     hospital medical committees, and most often it was
   4     helpful to share a view, being not a clinician I suppose
   5     I had a more formal view in relation to expectations of
   6     government circulars and other documents, a clinician
   7     would have a view with regard to the context of the
   8     issue as it came up, and it was a process of deciding on
   9     the nature and seriousness of the issue that came up and
  10     what action needed to be taken.
  11   Q. Did you have a formal role within the disciplinary
  12     structure, or was your role rather one of commenting,
  13     advising, upon the details of any particular case that
  14     had been drawn to your attention, and advising the
  15     Health Authority what ought to happen next?
  16   A. No. I felt that I had a formal role in this process and
  17     would, if necessary, take it further forward.
  18   Q. I think what I meant by that question -- I am not
  19     putting myself clearly -- was whether you were part of
  20     any formal disciplinary panel or tribunal that would
  21     have had the responsibility for judging such cases, or
  22     whether your advice was limited, if I may use that term
  23     without it meaning to sound derogatory, to advising on
  24     the particular steps that should be taken by the
  25     authority?

   1   A. It was the latter.
   2   Q. If we look at one of the circulars you have referred to
   3     in that paragraph, HC(90)9, that is to be found at
   4     HOME 1/221.
   5        This is the circular that replaced its
   6     predecessor, HM(61)112, but it governed disciplinary
   7     structures within the health authorities prior to the
   8     introduction of Trust status.
   9        I think I am correct in saying that although there
  10     are certainly differences between the two structures,
  11     they are similar in intent, if not in detail?
  12   A. I am guided by you, I am afraid.
  13   Q. If we could just turn briefly to page 222.
  14        We can see there, scrolling down, the definitions
  15     of the various categories of conduct that disciplinary
  16     procedures might need to deal with: personal conduct,
  17     professional conduct, professional competence.
  18        At page 226 we see there the structure of the
  19     beginnings of the circular details, but the structure of
  20     the steps that need to be taken if we scroll down.
  21     There are three types of cases, and we have seen the
  22     definition already. They are cases involving personal
  23     conduct briefly dealt with, and then "Preliminary
  24     investigation - establishment of a prima facie case":
  25        "The first step when an incident occurs or

   1     a complaint is made involving the professional conduct
   2     or competence of a medical or dental officer should be
   3     for the Chairman of the Health Authority to decide
   4     whether there is a prima facie case ..."
   5        If we turn over the page, we find there is
   6     provision for a panel of Inquiry to investigate the
   7     matter if it is thought that the Chairman needs such
   8     guidance or assistance.
   9        We see there that no member of the Panel should
  10     be associated with the hospital in which he works.
  11        Can I ask you first, Dr Baker, what was your role
  12     in relation to that structure: was it one of advising
  13     the Chairman of the Health Authority?
  14   A. Yes, it was.
  15   Q. And does it follow from the structure we have just been
  16     looking at that at least in theory, a structure in which
  17     decisions on whether or not a complaint should be
  18     investigated, acted upon, are made by the Chairman of
  19     the Health Authority, is a structure which should be
  20     able to cope with complaints being made against senior
  21     clinicians in a hospital within the control of the
  22     Health Authority?
  23   A. Yes.
  24   Q. If that is the position in relation to the structure
  25     that has been set up, do you think that in practice the

   1     way the structure operated was such as to enable the
   2     Health Authority to act properly against not merely
   3     a junior doctor, say, but a senior respected clinician?
   4   A. Yes.
   5   Q. And does anything from your involvement in the Health
   6     Authority's procedures up to 1991 lead you to think that
   7     that was how it worked? Is your answer based upon your
   8     experience?
   9   A. Yes and no. I think there was a recognition of this
  10     arrangement. My recall is not to have been involved in
  11     any instance of serious misconduct or incompetence, that
  12     actually brought this system into action. I might be
  13     mistaken, but I do not recall anything.
  14   Q. Is that because you were not necessarily involved in
  15     every case, or because as far as you can recollect at
  16     this instance, there were no such cases?
  17   A. I think it is a bit of both.
  18   Q. I am sure we can all understand that. If one turns
  19     back to your statement, paragraph 3, page 17 of the
  20     statement, you talk there about the "three wise men"
  21     which was a procedure intended to deal with medical
  22     staff whose mental and physical incapacity put patient
  23     safety at risk.
  24        Did you have any involvement or experience of how
  25     that structure functioned up to 1991?

   1   A. Yes, I did. This is where I shared matters with the
   2     Chairman of the Hospital Medical Committee. The "three
   3     wise men", at the time of the Health Authority, I think
   4     I am correct in saying, were the Chairman of the
   5     Hospital Medical Committee, his predecessor and his
   6     successor elect.
   7        My discussions with the Chairman of the Hospital
   8     Medical Committee would determine how far any concerns
   9     about mental or physical incapacity of staff could be
  10     resolved or whether or not we needed to actually -- it
  11     would not be me, but the Chairman of the Hospital
  12     Committee would bring together the "three wise men" to
  13     give advice.
  14   Q. I think it follows from what you said earlier that you
  15     were not aware of any complaint ever having been made
  16     against any of the members of the "three wise men" panel
  17     themselves, but what in theory would be the response of
  18     the system to such a situation arising?
  19   A. I think it would be to try and take advice from a higher
  20     level -- at District level, the District General Manager
  21     or the Chairman of the Health Authority, but also the
  22     Regional Medical Officer, or indeed, presumably the
  23     Regional General Manager. But certainly the Regional
  24     Medical Officer would be another person to whom one
  25     could turn for guidance.

   1   Q. Thank you. If we could turn on, please, to page 20 of
   2     your statement -- I am just about to start a slightly
   3     different topic, Dr Baker. It may just be that the
   4     moment would be a convenient one for a break, if that
   5     would suit you?
   6   A. Thank you for that, but I think I can keep going, thank
   7     you very much.
   8   Q. I will carry on for a little longer. We are looking
   9     here at the commentary on first of all Mr Wisheart as
  10     a key clinician. You comment at the end of that
  11     paragraph that at the time you "believed that there was
  12     good collaboration between Mr Wisheart and paediatric
  13     cardiologists, anaesthetists and other clinical
  14     disciplines and managers involved in paediatric cardiac
  15     surgery which with hindsight may not have been the
  16     case".
  17        Firstly, can I ask you: on what did you base your
  18     views of collaboration at the time?
  19   A. I think our contact with Mr Wisheart and other
  20     clinicians in the planning and then commissioning
  21     processes, and then, in parallel to that, we would be
  22     planning and commissioning for other children's
  23     services, meeting the same managerial staff some time or
  24     the same Clinical Directors, so it was that sort of
  25     contact that enabled one to have a view.

   1   Q. In your role as working for the District for really the
   2     entirety, if one includes your role for Avon Health, of
   3     the period of the terms of reference of the Inquiry, how
   4     often would you have come into contact with people such
   5     as Mr Wisheart, Dr Joffe, Dr Martin?
   6   A. I suppose a few occasions in most years. Sometimes it
   7     would be fairly intensive, if there is a change, like at
   8     the beginning of the period when there was detailed
   9     planning of an expansion of services or when there was
  10     a change to commissioning with the advent of the Trusts
  11     and the internal market and there was a requirement to
  12     take advice to formulate specifics of services for which
  13     we were going to contract.
  14   Q. Whereas at other times it would be more intermittent?
  15     Is that right?
  16   A. Yes.
  17   Q. When you say that "with hindsight that may not have been
  18     the case", what information is it that came to your
  19     attention at a later date that may perhaps have caused
  20     you to change your view?
  21   A. I think any part of the information from 1995 onwards.
  22   Q. Relating to ...
  23   A. Relating to the reports about paediatric cardiac surgery
  24     or the Inquiry -- well, particularly that, or
  25     subsequently about adult cardiac surgery.

   1   Q. You say "with hindsight that may not have been the
   2     case". Hindsight can do one of two things: it may
   3     either provide you with information that distorts what
   4     was in fact the true position, or it may be a question
   5     of new information giving you now a truer picture of
   6     matters at the time.
   7        Which do you think it is?
   8   A. It was certainly the latter.
   9   Q. So can you sum up what you think the position may in
  10     truth have been with the benefit of hindsight?
  11   A. I do not think I can very easily. I have only the
  12     knowledge of the documents which have reported on
  13     Bristol paediatric cardiac services, or adult services.
  14     I have no further internal knowledge of affairs within
  15     the Trust services.
  16   Q. So your hindsight knowledge is based upon documentary
  17     evidence rather than firsthand discussion with, say, the
  18     clinicians concerned?
  19   A. Correct.
  20   Q. If we turn down to the next paragraph, you make
  21     a similar statement at the bottom of that, that you
  22     believe there was good collaboration between Dr Joffe
  23     and relevant surgeons, other clinical disciplines and
  24     managers.
  25        With the benefit of hindsight, is there any

   1     rider or qualification that ought to be added to that,
   2     or not?
   3   A. I think the same qualification could have been added to
   4     this paragraph, or, indeed, otherwise left out of the
   5     paragraph on Mr Wisheart.
   6   Q. If we move on, please, to page 21 of your statement, you
   7     are dealing here with an issue that started at the
   8     bottom of page 20, the nature and scope of outreach
   9     clinics established by the cardiologists for services
  10     across the wider region.
  11        You make a number of points about the organisation
  12     of these services.
  13        In particular, could I ask you to turn firstly to
  14     a page WIT 74/449, where the historical position in
  15     relation to cardiological clinics in Gwent is set out
  16     and the letter writer says:
  17        "As you are doubtless well aware, a considerable
  18     number of patients from Newport have always come to the
  19     Children's Hospital in Bristol for their cardiac care
  20     and more recently we have had patients from other parts
  21     of Gwent."
  22        Are you able to help us on the reasons for the
  23     historical pattern of referral from Gwent and other
  24     parts of South Wales, but primarily, I think, from
  25     Gwent, to the Bristol Royal Infirmary?

   1   A. I do not think I can say very much more than assume it
   2     was due to proximity. Obviously this sort of letter,
   3     and perhaps others which you have, indicate a good
   4     understanding between paediatricians in Gwent and
   5     paediatric cardiologists, but again, I would assume that
   6     that was underpinned by proximity.
   7   Q. If we just scroll a little further thorough the letter,
   8     we see there Dr Jordan is concerned that there are major
   9     limitations with regard to admission of patients for
  10     investigation of heart conditions in the Children's
  11     Hospital, due to a shortage of beds consequent on the
  12     shortage of nursing staff.
  13        If we could just note that and move on, please, to
  14     page 451, there is a similar letter here to you this
  15     time discussing the question of a third paediatric
  16     cardiologist and doubts about it. If we just scroll
  17     through the letter briefly, you see there the concern
  18     being expressed by -- I think it is Dr Jordan, if we go
  19     down to the bottom of the page. The concern is being
  20     expressed that both he and Dr Joffe are both very
  21     heavily committed and they are being stretched by the
  22     requirement to hold clinics in other parts of the region
  23     or in Wales.
  24        You have given us again the details of the clinics
  25     that were run by the cardiologists, and also a number of

   1     references of similar letters making points about
   2     capacity and so on.
   3        In general, I think you note the absence of
   4     complaints about the service being provided in Bristol
   5     throughout your statement.
   6        If there were potentially two sorts of concerns
   7     that might be expressed about the service being run by
   8     the Bristol cardiologists: the first being that Bristol
   9     was not providing an adequate standard of care,
  10     therefore there was a reluctance to send children from
  11     Wales or from any other potential outreach clinic to
  12     Bristol, and the second being that Bristol, whilst it
  13     provided adequate standards of cover if one could reach
  14     it, was nevertheless experiencing difficulties in
  15     covering, allowing children access to its services;
  16     which of those two alternatives was the scenario that
  17     you were dealing with throughout the period you were
  18     responsible for this issue?
  19   A. I think I was dealing with other District officers with
  20     the speed of development of paediatric cardiac
  21     services. There were of course many facets to be
  22     developed in parallel, and one component was to have the
  23     right capacity of medical staff for the task, but there
  24     were other points like the adequacy of nursing staff,
  25     particular types of beds, facilities, et cetera. I had

   1     mentioned earlier to you we were not trying to cope
   2     along with developments in paediatric cardiac service,
   3     but other paediatric services within the totality of
   4     other planning priorities within the District.
   5        This is an example of a case being made quite
   6     strongly and clearly by a paediatric cardiologist about
   7     the pressure that they were feeling under in trying to
   8     provide what they thought was an adequate service, and
   9     how -- not easy, but how appropriately that pressure
  10     could be relieved by the addition of a further
  11     cardiologist. In a planning sense, I had to take part
  12     with others in how quickly that could be addressed and
  13     in what order in relation to other planning priorities.
  14   MISS GREY: Dr Baker, I think it probably would be
  15     appropriate if we took a short break at this moment,
  16     perhaps for approximately a quarter of an hour.
  17   THE CHAIRMAN: Yes. Shall we say 5 past 12?
  18   (11.51 am)
  19               (A short break)
  20   (12.10 pm)
  21   MISS GREY: Dr Baker, before we broke, I was asking you
  22     a question which was along the lines of what sort of
  23     service you thought you were dealing with as a planner
  24     up to 1991. There could be two different types of
  25     service. You can either have a service which is

   1     struggling because people are reluctant to use it, to
   2     refer to it; or you can have a service which may be
   3     struggling to cope with the demands upon it by way of
   4     referrals to it. Which one of those two alternatives,
   5     or perhaps a third, did you think you were dealing with
   6     up to 1991?
   7   A. The second of your two options.
   8   Q. Is that really the theme that runs through the subject
   9     of your evidence on the Welsh referrals issue and the
  10     consequent response of planners which was to sort out
  11     funding for cross-boundary allocations in the context of
  12     those pressures?
  13   A. Yes. That was certainly a considerable element applying
  14     to children over the age of 1, and trying to clarify the
  15     funding for the referrals that took place. I mean,
  16     there were other planning dimensions to our
  17     relationships with Welsh authorities, obviously in terms
  18     of outreach clinics which you have mentioned, and some
  19     attempt to come to an understanding with South Glamorgan
  20     Health Authority about any opportunities to share
  21     development of cardiac services for children.
  22   Q. And you turn to that, in fact, when you talk about the
  23     mixture of collaboration and common purpose, but also
  24     some rivalry in this issue -- I am looking at page 24 of
  25     the statement. What were the themes of collaboration

   1     and common purpose, first?
   2   A. I think my contact with public health physicians and
   3     others in South Glamorgan made it clear that resourcing,
   4     particularly in terms of staff, cardiac services for
   5     children both in Bristol and in Cardiff was very
   6     difficult. In particular, there seemed a limited number
   7     of Senior Registrars waiting to come forward and take up
   8     posts in paediatric cardiac services and we explored
   9     whether there was any possibility or benefit from
  10     sharing posts in some way. So that certainly was the
  11     nature of one aspect of our involvement.
  12   Q. When you talk about there being some rivalry, what do
  13     you mean by that?
  14   A. It is certainly apparent now, perhaps not so much so at
  15     the time, that in essence a potential cardiac service
  16     from Cardiff and the continued development of services
  17     in Bristol were competing for the same catchment
  18     population of patients to come into services and both
  19     the further development of the throughput in Bristol,
  20     which we talked about earlier this morning, and getting
  21     throughput off the ground in Cardiff, essentially
  22     depended on access to the same children. In a way, it
  23     turned out to be rivalry.
  24   Q. Is it fair to say that the attitude of the clinicians
  25     in Bristol was that they supported the case for

   1     children, the under 1s, the over 1s, to be sent to them
   2     rather than to Cardiff?
   3   A. Correct.
   4   Q. If we are looking at page 22 of your statement, please,
   5     you talk about, there, the patterns of referral, firstly
   6     from regional and special health authorities. You
   7     mention there a particular factor, which was that London
   8     hospitals within the special health authorities were
   9     able to charge costs that were lower than the costs of
  10     using services in Bristol.
  11        Was this then a factor that you believe had
  12     influenced and continued to influence referral patterns
  13     throughout our period?
  14   A. Yes. I believe it did. What I cannot help you with
  15     is knowing if it would have applied to children
  16     over 1 or not. Obviously the vast bulk of referrals
  17     were adults from Cornwall, Devon or other places, but
  18     the same reasoning will apply to children over the age
  19     of 1 outside the supra-regional service. But I cannot
  20     be specific as to whether or not it applied to children.
  21   Q. Because you are not discussing there the funding
  22     incentives or otherwise for the under 1s?
  23   A. That is right.
  24   Q. To which this point would not apply?
  25   A. Yes.

   1   Q. But are you saying, Dr Baker, that the referral patterns
   2     were influenced there by non-clinical matters, but by
   3     financial matters?
   4   A. I hesitate because the immediate answer would seem to be
   5     "Yes", but there could well be other reasons, including
   6     in particular perhaps strong historical links between
   7     referring physicians in the likes of Devon and Cornwall
   8     to centres in London which had developed expertise and
   9     become centres of excellence in the past. There might
  10     have been strong clinical ties which were active as
  11     well.
  12   Q. And "clinical ties" means what? Are you talking about
  13     outreach clinics, or personal contacts and friendships,
  14     or what?
  15   A. Personal contacts and friendships, but I think probably
  16     more so the whole nature of training, that if you had
  17     come from a medical school in London and you worked your
  18     way up into a consultant post at some distance from
  19     London, you might still consider that the person who
  20     taught you in London was the best provider of services.
  21   Q. So when you say a "historical pattern" might influence
  22     referrals, you are talking perhaps not merely of the
  23     record of referrals from the institution from which the
  24     referring paediatrician comes, but also possibly the
  25     links that that person had as a trainee that might

   1     influence him or her at a later date?
   2   A. Correct.
   3   Q. If we go on, please, furthermore to turn to the subject
   4     of your involvement with negotiations on the Welsh
   5     referrals, at paragraph 9.5, page 25, you talk about the
   6     difficulties that both South Glamorgan and Bristol had
   7     in attracting paediatric cardiologists with South
   8     Glamorgan advertising but having only two unacceptable
   9     candidates, and Bristol attracting four applicants but
  10     four withdrew before interview.
  11        You talk about speculation or interpretation as
  12     to behind-the-scenes manipulation of the very limited
  13     number of suitable candidates.
  14        What exactly do you mean by that? What was the
  15     nature of the speculation at the time?
  16   A. I think first of all we found this experience very
  17     unusual indeed. In fact, I do not think myself all
  18     medical staffing officers have experienced this
  19     happening before. Because of the sequence of events, we
  20     wondered if there was some manipulation, and it was part
  21     of the possible feeling that neither side, if you like,
  22     Cardiff nor Bristol, was going to get ahead with these
  23     very limited number of Senior Registrars who were
  24     available for the next consultant post.
  25   Q. But who might have been manipulating whom?

   1   A. I obviously can in no way be specific. The expression
   2     that comes to mind, there is obviously a very close
   3     network in the subspecialties in clinical services,
   4     whereby Royal Colleges know who is being trained and who
   5     is coming through the pipeline at any one stage and if
   6     they valued potential new consultant material, they will
   7     be known about and effort will be made to try and help
   8     them into appropriate locations.
   9   Q. In any event, this was all speculation on the part of
  10     those you knew?
  11   A. Correct.
  12   Q. One cannot, perhaps, get any further as to what might
  13     have influenced the candidates?
  14   A. Correct.
  15   Q. If the powers that be, as it were, did not want either
  16     to get ahead, appointments to be made either at Bristol
  17     or Cardiff at the time, why might that have been so?
  18     What might have been the motive for that?
  19   A. I think it comes back to the earlier point I made about
  20     the desire, at least in South Glamorgan, in South Wales,
  21     for comprehensive cardiac services to develop there in
  22     South Glamorgan for Wales or at least South Wales, with
  23     the equally strongly held desire by Bristol cardiac
  24     clinicians to develop services in Bristol. That was
  25     clearly defined by the fact that there was a common

   1     catchment population; it was recognised that there was
   2     some legitimacy through the South Wales population being
   3     considered the legitimate catchment population for the
   4     supra-regional services in Bristol, but Cardiff could
   5     not get off the ground if Bristol was taking all the
   6     patients from South Wales.
   7   Q. In any event, you go on to say that the Cardiology
   8     Committee of the Royal College of Physicians in London
   9     offered help by reviewing matters, and you talk about
  10     the visit of the committee as a result.
  11        Can I ask you, at paragraph 9.5 on page 25, if we
  12     scroll down the page to 9.8, where you have been
  13     discussing the offer of help from the Cardiology
  14     Committee, you talk about, in 9.8, a response from
  15     Doctors Jordan and Joffe which was copied to Dr Jane
  16     Sommerville, who was on that committee asking that
  17     Bristol be included in the review, did you have any
  18     involvement in the activity of the review when, in
  19     particular, they came to Bristol?
  20   A. I sat in on one of the meetings when Dr Sommerville
  21     met the clinicians.
  22   Q. Can you recollect any of the discussions that took
  23     place?
  24   A. Not very clearly at all, no.
  25   Q. Was there any discussion of the throughput or numbers

   1     going through Bristol, or can you not say?
   2   A. No, I cannot say. I cannot recall whether I was there
   3     for the whole meeting or not. I certainly remember
   4     meeting her when she came to Bristol. I cannot remember
   5     the content of the meeting.
   6   Q. If you go on then to page 26, where you have described
   7     Doctors Jordan and Joffe drawing attention to what they
   8     termed a "campaign of vilification" by the Welsh Heart
   9     Circle and you draw attention to their letter in reply,
  10     on what, if anything, did you understand that this
  11     campaign for vilification was based?
  12   A. I think I was receiving this as a report. I think at
  13     the time I had to try and reflect if this was important
  14     or whether it was possibly part of a lobbying process
  15     for the development of services in South Wales. I think
  16     those were my probable thoughts at the time.
  17   Q. If we look at the document that was written by the two
  18     commissioners that you have mentioned there in response
  19     to this campaign, it is to be found at UBHT 133/29.
  20     That is the text of the letter. If we go to page 35, we
  21     see there a comparison presented between Bristol results
  22     and UK results, presented by the cardiologists as
  23     a defence or answer to the criticisms that have been
  24     made of the unit.
  25        Looking at the figures for open heart surgery, it

   1     is possible to see that there is a contrast in the
   2     figures for the Bristol results, 1984 to 1986 and the UK
   3     results. Firstly, in relation to over 1 year, where the
   4     Bristol results are 7.9 percentage deaths based on 19
   5     deaths. In the UK that figure is 6.9.
   6        If one looks at open heart surgery for under 1s,
   7     the respective figures are 26.5 per cent and 21.8 per
   8     cent for the United Kingdom.
   9        That is a difference of 4.7 per cent between the
  10     two. It might be said, perhaps, that the Bristol
  11     results appear to be significantly worse than the United
  12     Kingdom results.
  13        What were your contemporaneous thoughts about that
  14     difference?
  15   A. I think most simply that they were not significantly
  16     worse, so that I suppose my thoughts at that time, or
  17     even now, would be that they do not represent something
  18     which is worse and that certainly I myself -- I cannot
  19     speak for the cardiac clinicians -- may or may not have
  20     understood at that time what the meaning of these
  21     differences truly were. I refer in my evidence to
  22     considerable understanding of the complexity of making
  23     comparisons which evolved throughout the period, and in
  24     fact are still with us, so my reflection at that time
  25     would be that it was to the contrary, that I think

   1     probably this was put forward as a document to show that
   2     there was similarity in outcome.
   3   Q. And the thrust of your evidence is that you accepted it
   4     as such?
   5   A. Correct.
   6   Q. You talk in your evidence in general -- we have seen
   7     some of it in some of the letters we have seen relating
   8     to your audit of adults, relating to your correspondence
   9     with the Society of Cardiothoracic Surgeons, about your
  10     developing understanding of the complexities of figures,
  11     of making comparisons between mortality rates. You have
  12     given us many of the reasons for that at page 45 of your
  13     statement.
  14        If we turn back the clock to 1988, can you try and
  15     help us further as to what you think your understanding
  16     or level of knowledge would have been at that time in
  17     relation to those complexities?
  18   A. I think it would have been less developed and partial.
  19     I think it would have addressed some aspects of the
  20     problems of definition, the problems of grouping
  21     together, into collective figures, children with
  22     different defects having different procedures, the whole
  23     problem simply of comparing oranges with oranges and not
  24     with apples, and also understanding what the UK register
  25     as a benchmark meant.

   1        I can recall uncertain views as to whether it was
   2     a robust tool with which to make comparisons or not, and
   3     some feeling that it was not, but in the absence of
   4     anything else, it was used. Then I think it became even
   5     more difficult because I think at times figures were
   6     used to give emphasis to different messages.
   7   Q. If you had difficulties in interpreting data such as
   8     this, who did you understand would have the necessary
   9     expertise to do it properly, if anyone at all?
  10   A. Certainly at this stage -- and I think probably it is
  11     outside the period -- before, for children, one was
  12     getting to grips with the complexity of this. My
  13     immediate advice came from local paediatric
  14     cardiologists and surgeons, and --
  15   Q. By "local" you mean based at the Bristol Royal Infirmary
  16     or the Children's Hospital?
  17   A. Correct, yes. I accepted their advice.
  18   Q. Was your attitude to this particular document in any way
  19     influenced, or relevant in any way that it was in fact
  20     addressed to Dr Chamberlain of the Royal College of
  21     Physicians in the context of the Royal College of
  22     Physicians' proposed review of the services in Wales and
  23     their interrelationship, perhaps, with Bristol?
  24   A. I certainly saw the coming into being of the College
  25     Working Party to help several aspects of this situation

   1     in Wales, but it was clearly coupled with the fact that
   2     there were some indications from some quarters that the
   3     service in Bristol was less than satisfactory. Hence
   4     the nature of the riposte by the Bristol cardiac
   5     physicians that it was not the case and trying to use
   6     figures like this to support the view. So one would
   7     hope and suppose that the members of the Working Party
   8     would have used these sort of figures and any other
   9     figures which were available to them in coming up with
  10     their assessment.
  11   Q. But would you have assumed that they would have been
  12     better placed than you were, say, to assess the
  13     relevance or the case that was being presented by these
  14     figures?
  15   A. I would have assumed that at the time, certainly with
  16     hindsight, I think they would have found the same
  17     complexity of interpretation as we now know exists.
  18   Q. When you said just a moment ago that concerns were being
  19     expressed in some quarters about the adequacy of the
  20     service in Bristol, is that a reference back to the
  21     Heart Circle in Wales campaign?
  22   A. Yes.
  23   Q. Or were you referring to anything else?
  24   A. No, it was certainly that campaign, and then I was aware
  25     of Professor Henderson's concerns, but again, I get

   1     slightly confused here as to what I know now and what
   2     I knew at the time.
   3   THE CHAIRMAN: If I may interject, because you used the word
   4     "indications" from some quarters. Did you mean by that
   5     there was some evidence to indicate, or did you mean
   6     that there were allegations being made or something
   7     else? I am referring to what you said a moment ago.
   8   A. I am sorry, would you give me the context?
   9   THE CHAIRMAN: Would it help if I read it out? You said "it
  10     was clearly coupled with the fact that there were some
  11     indications from some quarters that the service in
  12     Bristol was less than satisfactory."
  13        Then you saw the Bristol response as a riposte to
  14     that. I was just asking you about the word
  15     "indications"?
  16   A. I think the word "indications" I was using in terms of
  17     what had been reported to me about the Welsh Heart
  18     Circle, and I am trying to clarify in my mind the role
  19     with regard to Professor Henderson. As I said, I was
  20     having difficulty determining whether it is material
  21     I have read very recently, because I cannot recall from
  22     my statement that I say that I had any other indication
  23     of advice from Professor Henderson. He was party to
  24     some of the meetings I took part in, but I do not recall
  25     any particular indications from him.

   1   MISS GRAY: If it assists, for instance, the record of the
   2     meeting on 7th March 1988, which you discuss at
   3     paragraph 9.10, page 26, is not a meeting, for instance,
   4     that records any views being expressed by Professor
   5     Henderson that would be critical of the Bristol service.
   6        I will be corrected if I am wrong, but I think it
   7     is the case that the other meetings that you attended
   8     (certainly that of March 1989) do not either suggest
   9     that those views were being expressed by Professor
  10     Henderson in your presence.
  11   A. Correct.
  12   Q. Would it perhaps be fair to say that if Professor
  13     Henderson was expressing views that were critical in any
  14     way of Bristol, those would have been expressed in
  15     meetings with you, and that the best guidance,
  16     therefore, to what was or was not said to you would be
  17     found in those meeting minutes, rather than by
  18     attempting to press you here and now on what your
  19     recollection is at this date?
  20   A. Yes, if that was the case. I cannot recall, even at
  21     meetings in which Professor Henderson was taking part,
  22     that occurring, but that would be a source of evidence,
  23     yes.
  24   Q. I think what is implicit in much of your evidence is
  25     that you did not have any separate dealings with him

   1     that might have resulted in informal contacts?
   2   A. Correct.
   3   Q. Briefly, to finish that, you talk also of a similar
   4     table being prepared by Bristol, if we look at page 42
   5     of your statement, the second item there -- we have
   6     discussed already the first item.
   7        This is a second series of tables prepared by,
   8     perhaps, the cardiologists, the Bristol cardiac
   9     clinicians, and contained in supporting tables for the
  10     meeting of 7th March 1988.
  11        Would the answers that you have given in relation
  12     to your understanding of the data at the time be similar
  13     in relation to that?
  14   A. Yes, they would.
  15   Q. And at the time, would you have regarded it as being any
  16     of your responsibility, as it were, to assess the
  17     accuracy or otherwise of the material being presented to
  18     such a meeting?
  19   A. No, certainly not directly.
  20   Q. But in terms of your overall planning function, did you
  21     have any responsibility to check that the service for
  22     either the under or the over 1s was producing an
  23     acceptable outcome?
  24   A. Yes, certainly in terms of children over 1, they were
  25     part, obviously, of our overall planned or later

   1     commissioned services. Within the breadth of our
   2     responsibilities for understanding whether we were
   3     getting the services we wanted to, that would have been
   4     generally the case.
   5   Q. And in relation to the under 1s?
   6   A. Not in relation to the under 1s. My understanding
   7     always was that the supra-regional service was
   8     supervised through their own arrangements. From time to
   9     time, as these tables illustrate in other contexts or
  10     for other purposes, figures which were I assume supplied
  11     to the supra-regional service were shared with me. That
  12     is what I am trying to capture in these tables.
  13   MISS GREY: Dr Baker, I think again it might be a convenient
  14     moment for a break, if we might break for a quarter of
  15     an hour.
  16   THE CHAIRMAN: I am in your hands and those behind you. An
  17     alternative, since we have not discussed this, would be
  18     to take a half an hour lunch break now and reconvene at
  19     just after 1, or I will be advised by you.
  20   MISS GREY: Could I have a moment, please? (After
  21     conferring): If Dr Baker would not veto the suggestion,
  22     the feeling from here is that a half an hour lunch break
  23     would be preferable.
  24   THE CHAIRMAN: Then that is what we will do. Shall we say,
  25     looking at my clock here, that we reconvene at around

   1     10 past 1.
   2   (12.40 pm)
   3            (Adjourned until 1.10 pm)
   4   (1.12 pm)
   5   MISS GREY: Dr Baker, before lunch we were looking at
   6     the second item on your table at page 42.
   7        If we could turn to the data itself you were
   8     referring to there, at UBHT 167/32 in particular, this
   9     is one of the two tables referred to in table 2 that was
  10     supplied to the meeting and used the meeting on
  11     7th March.
  12        If we scroll down a little, we see that the table
  13     in general is 30-day mortality following surgery for
  14     congenital heart disease in Bristol and the UK by
  15     diagnosis, the under 1 years.
  16        In general, one can see there is a comparison
  17     being drawn there of the results in Bristol in 1984 to
  18     1987 and the UK results from 1984 to 1985, presumably
  19     because later information might not have been available.
  20        If one drops to the bottom, the percentage death
  21     rate for Bristol is recorded as being 27.0, whereas that
  22     of the UK is 21.4.
  23        Then there is a third table, calculated deaths in
  24     Bristol if UK mortality were applied to the categories
  25     of operations in Bristol.

   1        The result there is 19.24.
   2        So if UK mortality rates were applied to Bristol,
   3     the mortality rate would drop, on this table, from 27 to
   4     19.24.
   5        You say at table 2 that when you saw this data,
   6     the mortality rates by diagnosis and age were very
   7     variable and you point out various things such as 28 out
   8     of the 74 children under 1 year are given a diagnosis of
   9     "miscellaneous", it is not further categorised.
  10        Looking at that table, does it not suggest that on
  11     those figures alone, or looking at those figures alone,
  12     there is a significant difference between the mortality
  13     rates being recorded as taking place in Bristol and
  14     those in the UK as a whole?
  15   A. I would say not, really, for the same reasons as we
  16     discussed the table which showed them before lunch. If
  17     I might come back to the point you made with regard to
  18     this table and the calculations on the right-hand side,
  19     I think this was somebody's attempt to actually
  20     calculate the actual number of deaths, not the
  21     percentage mortality. So that comparison of what number
  22     of deaths would have taken place in Bristol if the UK
  23     mortality had applied of 19 in whole person figures, is
  24     to be compared with 20 deaths under the column of the
  25     number of deaths there for Bristol.

   1        So, in other words, there would have been one
   2     extra death in Bristol had the implied UK standard
   3     applied.
   4        I think that is the interpretation of those
   5     tables.
   6   Q. So what you are saying is that the correct
   7     interpretation of that table is that the two are broadly
   8     comparable?
   9   A. Correct.
  10   Q. Because if the UK mortality is applied, there would have
  11     been 19.24 deaths?
  12   A. Correct.
  13   Q. So if you can put yourself back into the mind you were
  14     in in 1988, then, rather than 1999, is it fair to say
  15     that you read the table in that form then, and therefore
  16     did not see any reason to suppose that Bristol's
  17     mortality rates were out of line with the rest of the
  18     United Kingdom?
  19   A. Yes, I think so.
  20   Q. And it is also right to record that if we go to the
  21     minutes of the meeting of 7th March, which are to be
  22     found at WIT 74/493 -- we will not, I think, turn them
  23     up because the point I wish to make is a negative one --
  24     there is no record there of any discussion about concern
  25     or any discussion of the quality of the service at

   1     Bristol, or anything to suggest that the meeting was
   2     concerned in any way by the quality of the service being
   3     provided at Bristol.
   4        Would that accord with your recollection?
   5   A. It would.
   6   Q. So the contemporaneous conclusion one might draw from
   7     that is that all those who were present at the meeting
   8     who had received this table data had not seen anything
   9     in them that was worthy of discussion, note or comment
  10     as representing concerns about the quality of the
  11     service?
  12   A. Correct.
  13   Q. Turning back to your statement at page 26, you refer to
  14     the fact at paragraph 9.11 that you received an extract
  15     of the review of the cardiac services in Wales by the
  16     Cardiological Committee of the Royal College of
  17     Physicians.
  18        It is right, is it, that you received only an
  19     extract and never the full report?
  20   A. That is correct.
  21   Q. If one looks at the conclusion that is summarised at
  22     paragraph 9.11, we see that "until satisfactory
  23     paediatric cardiac facilities are established at
  24     University Hospital, Wales, and accepted as satisfactory
  25     by referring physicians in South Wales, the present

   1     radiated referral arrangements will have to continue."
   2        What conclusion did you draw from that?
   3   A. The conclusion was that I saw Bristol as included in
   4     radiated referral arrangements and endorsement that
   5     referral to Bristol continuing could be expected.
   6   Q. There is a possible interpretation of that sentence in
   7     that by speaking of the present radiated referral
   8     arrangements having to continue, it suggests only
   9     perhaps a grudging endorsement of the existing
  10     arraignments.
  11        What would be your comment on that?
  12   A. I accept your view that that could be one
  13     interpretation. I think another interpretation would be
  14     that this document was requested for being reported to
  15     the Welsh Office considering centrally the opportunity
  16     to develop the service in South Wales. I think that
  17     could be another interpretation.
  18   Q. In other words, that the present radiated referral
  19     pattern was second best in so far as what the report was
  20     recommending, which was the development of an in-house
  21     service in Wales, as it were, but until that could be
  22     established, one would have to use the existing pattern
  23     of referrals?
  24   A. Yes.
  25   Q. Turning to page 28 of your statement, you speak there of

   1     the supra-regional funding system and you make the point
   2     at paragraph 5 of your statement that you were not aware
   3     of any specific bid for supra-regional services in
   4     Bristol emanating from the BRI or the Children's
   5     Hospital, although there was a canvassing of the
   6     possibility in various documents. You go on to say that
   7     it was after designation that the Supra Regional
   8     Services Advisory Group asked the DHSS to initiate
   9     studies of services in each unit.
  10        From the perspective of someone who was involved
  11     in the planning and development of services within the
  12     District at that time, is that the process you would
  13     have expected to see in considering whether or not
  14     a particular service should be developed at one hospital
  15     or another?
  16   A. I would have expected to have seen or have some
  17     knowledge of the involvement of Bristol in the bidding
  18     process. I was not aware of that and I was not sure if
  19     that had happened before my involvement, or whether the
  20     appointment of Bristol had been through some other
  21     process.
  22   Q. When you say you would have expected Bristol to be
  23     involved in the bidding process, that implies that there
  24     was an established bidding process. What do you mean by
  25     that?

   1   A. I think there was, in so far as the documents supporting
   2     the supra-regional services in general pursued that
   3     approach. I have later knowledge, not quoted in my
   4     evidence, of attempts by Bristol, for instance, to
   5     secure cardiac transplantation services. That was of
   6     the nature of putting forward an application, bidding,
   7     if you like, for that service in competition with
   8     others.
   9        My understanding from the documents supporting the
  10     supra-regional services in general is that that would
  11     have been the expectation for Bristol receiving its
  12     designation.
  13   Q. If no formal bidding process is undertaken so units do
  14     not have to go through the process of preparing such
  15     a bid, does it matter or does it just save on
  16     paperwork?
  17   A. One would like to think that there were reasons for
  18     the bidding process and that the criteria used and
  19     offered were meaningful and allowed some differentiation
  20     between those who had to make the decisions as to where
  21     services should be best placed. But equally, I suppose,
  22     there could be other reasons why, if bids were not
  23     coming forward in the way in which it had been hoped but
  24     there was nevertheless a desire still to set up
  25     services, then some other more direct approach for

   1     appointment could take place.
   2   Q. If the process of bidding may help the person receiving
   3     the bids to assess the rival merits of the particular
   4     centres, does it also have any value for the purpose of
   5     preparing a bid from a planning point of view?
   6   A. Yes, it would, in so far as one would anticipate that
   7     one would need to make that bid realistic and that would
   8     involve several facets of the future provision of
   9     a service, both in terms of clinical objectives but also
  10     in terms of facilities and supporting services being
  11     brought together. So it would be like a planning
  12     exercise.
  13   Q. In the event, though, the service was developed by
  14     Bristol after designation in so far as the implications
  15     of designation were thought through by clinicians and
  16     planners thereafter. Were you aware of any particular
  17     strains or difficulties caused by addressing the
  18     implications of designation after the event, rather than
  19     perhaps to a greater extent than before?
  20   A. It is hard to answer those questions, really. My
  21     feeling was that the existence of the supra-regional
  22     service which was there when I became involved in
  23     planning allowed the ready facility of estimating
  24     a workload for the service and having it funded, so that
  25     was very helpful.

   1        I suppose many of the issues that we have talked
   2     about already today were ones of speed and the
   3     phasing-in of the growth of the service, both in its own
   4     right and alongside other children's or cardiac
   5     services.
   6   Q. If you turn to page 29, you tell us at paragraph 14 that
   7     you have on file a paper setting out a contract
   8     labelled "Draft 2" of November 1990.
   9        Were you ever told or were you ever sent the final
  10     contract?
  11   A. No, I was not.
  12   Q. Is this the only contract relating to the agreement
  13     between the Department of Health and the supra-regional
  14     service that you have been able to locate?
  15   A. The only advice I have located, yes.
  16   Q. The only --
  17   A. The only pattern of advice in this way that I am aware
  18     of, yes.
  19   Q. This particular document referred to monitoring of some
  20     aspects of clinical services in so far as it talked
  21     about information to purchasers including an annual
  22     report involving volume, case mix and quality
  23     parameters.
  24        Did you in fact ever receive, from the Department
  25     of Health, any of the documents that might have related

   1     to any monitoring of the outcomes at Bristol that they
   2     might have been receiving from the unit?
   3   A. I did not, no.
   4   Q. So does it follow from that answer that you do not know
   5     what level of monitoring, if any, of the standards or
   6     outcomes at Bristol --
   7   A. Yes.
   8   Q. I am sorry, that you do not know what monitoring or
   9     standards of outcomes at Bristol was being performed by
  10     the Department of Health?
  11   A. Yes. I did not know, if that is the correct answer,
  12     yes.
  13   MISS GREY: I am sorry for the garbled question. I think
  14     the Chairman would quite rightly wish to intervene.
  15   THE CHAIRMAN: Certainly not on that score. I was just
  16     concerned that all of those behind you had a copy of
  17     that document, which was, I know, circulated a little
  18     later than some.
  19   MISS GREY: The document in paragraph 14?
  20   THE CHAIRMAN: The contract document.
  21   MISS GREY: It is to be found at WIT 74/566.
  22        If we go over the page, paragraph 16, you talk
  23     there about the study performed by BDO Consulting and
  24     the details, the protocol that they had developed.
  25        What was your understanding of the purpose of this

   1     study?
   2   A. Its timing was around the introduction of the Trusts and
   3     the purchaser/provider divide and the internal market,
   4     so its approach and style was in relation to improvement
   5     of management of services and documentation of activity.
   6   Q. But you would not, I think, be in a position to comment
   7     whether or not it was used in any shape or form by the
   8     Department of Health, either before or after the
   9     decision to de-designate the service?
  10   A. No. That is correct, yes.
  11   Q. If we turn to the question of de-designation, you
  12     comment at paragraph 17 that de-designation occurred for
  13     the financial year 1994/95 and that you went on that
  14     year to commission cardiac services on the basis of
  15     a block contract.
  16        What scrutiny of the details of the service
  17     provided for the under 1s were you able to undertake
  18     before placing that contract?
  19   A. Very little. The advice from regional level -- I think
  20     it was the Regional Health Authority at the time -- was
  21     to maintain the steady state on de-designation. The
  22     steady state was not further defined or broken down, so
  23     it was a case of picking up on available advice and
  24     information from that point, within the District.
  25   Q. You then point out that you became aware, in 1995, after

   1     receiving the report by de Leval and Hunter -- would
   2     that be in about February 1995?
   3   A. Correct.
   4   Q. -- of the need to understand better the current approach
   5     to paediatric cardiac care. I think, as a result of
   6     that, you had a meeting with Drs Joffe and Martin to
   7     discuss aspects of current cardiological intervention
   8     and their success rates; is that right?
   9   A. That is correct.
  10   Q. You wrote a paper as a result of that, which you
  11     circulated.
  12        You then make a case, at paragraph 19, as to the
  13     limitations of the guidance that was available to
  14     individual health authorities by way of advice after
  15     de-designation.
  16        If we could just look, please, at the letter which
  17     you wrote as a response to this, it is to be found at
  18      HA(A) 100/20.
  19        In particular, if we look at paragraph 2, we see
  20     there that most often the push is from providers rather
  21     than from purchasers in terms of their ability to
  22     control the type of procedure that is being undertaken.
  23        If we turn over the page, we see there that you
  24     are making the point that many new approaches radiate
  25     out from international centres and there is very little

   1     quality control either of the nature of the procedures
   2     undertaken or the results that are experienced.
   3        Then affordability, if we scroll on: little is
   4     known. Monitoring: again, not well covered on
   5     monitoring.
   6        It would be fair to summarise that letter, would
   7     it, as saying in many ways that firstly you needed
   8     a great deal more expertise to be able to manage these
   9     services adequately as purchasers?
  10   A. Yes, I think that is correct. I think another way of
  11     addressing the answer would be to say that with
  12     de-designation, the requirement for a service and the
  13     type of service first became a subject matter for those
  14     of us in public health medicine to bring in dimensions
  15     which may not have been developed as fully as they might
  16     have been by clinicians in giving advice on the
  17     service. I think that was confirmed in my discussions
  18     with Drs Joffe and Martin that there were lots of
  19     questions which are identified in this letter which
  20     I felt needed some address.
  21        As these services had previously been generated
  22     nationally, I turned to a national figure at the
  23     Department of Health to provide this advice.
  24   Q. Can we just scroll up the page again once more? The
  25     second paragraph there appears to be making the point

   1     that in fact the effectiveness and efficiency would be
   2     better upheld if fewer rather than more centres
   3     undertake rare procedures. That, of course, was the
   4     rationale behind the creation of the supra-regional
   5     services in the first place. What did you understand to
   6     be the mechanism that might achieve that end once the
   7     service was de-designated?
   8   A. I felt there was no easy mechanism at all, other than
   9     contemplating some very difficult collaboration between
  10     District Health Authorities in trying to agree where
  11     purchasing might be focused, and that would be extremely
  12     difficult as well. I think, if you like, the practised
  13     approach had been that which was carried out through
  14     designation of 9 centres, and one could not, from the
  15     information available on de-designation, hesitate to
  16     know whether 9 had been felt to be the right number or
  17     too many or too few.
  18        If I might go on to say, I am aware that the
  19     Inquiry has already received advice from the view of
  20     these specialised services undertaken by the Audit
  21     Commission in 1997, which seemed to pick up the same
  22     point: that unless there was some central co-ordination
  23     of the development and monitoring of services in these
  24     specialised areas of small numbers of patients, then it
  25     was very difficult for the Health Authority to do so.

   1   Q. I think you are referring there to the Audit
   2     Commission's report published in 1997 on the
   3     commissioning for specialised services?
   4   A. Correct.
   5   Q. Looking back on it, with the benefit of hindsight again
   6     from 1999, do you think it would have been helpful if
   7     the Department of Health had issued guidance on these
   8     sorts of issues at the same time as de-designating or
   9     putting into effect the de-designation of the services?
  10   A. One can only say yes. I think it would not have been an
  11     easy task, but I think there could have been some sort
  12     of guidance, at least within which further debate and
  13     discussion could take place, but essentially, it was
  14     left to each individual purchasing Health Authority with
  15     very small numbers of children demanding these services
  16     to try and work out.
  17   Q. And the fact of the matter is that in 1994/95 you
  18     continued to commission on the basis of a steady state
  19     with very little scrutiny of the existing service for
  20     the under 1s or its adequacy?
  21   A. Yes.
  22   Q. If guidance had been forthcoming from the Department of
  23     Health, do you think that some of these issues, or the
  24     complexities of some of these issues, would have been
  25     apparent to you at an earlier date than they were in the

   1     event?
   2   A. I do not know necessarily. It would have brought up the
   3     whole issue of transition from a service which was run
   4     largely under its own steam; although obviously being
   5     a host Health Authority for cardiac services, we
   6     probably knew more of the nature of that service than
   7     had we been a more distant Health Authority not having
   8     cardiac services in its district.
   9        So I think the guidance would have had to have
  10     coped with the nature of the transition. One could
  11     think in terms of, again, ways in which that could have
  12     been led more by one district or one grouping of
  13     districts than another.
  14   Q. Because looking back on this matter now, again with
  15     the benefit of hindsight and we have referred briefly
  16     already to the Hunter/ de Leval report and your
  17     increased knowledge of matters within the Royal
  18     Infirmary thereafter, do you think there is any
  19     difference of approach that you might have adopted in
  20     1994 when de-designation took effect that would in any
  21     way have influenced how you placed the contract from
  22     1994 to 1995, or its terms?
  23   A. I think the quick answer is "No". Although we have
  24     talked about the desirability of understanding better
  25     what might have been better, I suppose in fairness, the

   1     steady state was probably the best advice. I think it
   2     reflects the fact that my appreciation of the
   3     supra-regional services and the designated centre was
   4     that it was trying to do a variety of things in terms of
   5     developing the service, developing skills, improving the
   6     outcomes of all manner of cardiac defects
   7     progressively. My observations were the difficulty of
   8     determining what would be considered to be the core
   9     services of procedures of clear benefit and what were
  10     services which were in development from which we could
  11     be uncertain as to whether the benefit over the natural
  12     mortality of the condition was going to be substantial
  13     or not, let alone having any view as to what
  14     "substantial" meant in the circumstances.
  15   Q. I think it is implicit in what you are saying, then,
  16     that the point is that there were no easy answers to
  17     those questions, whether they were asked in 1995, 1996
  18     or 1994?
  19   A. Correct.
  20   Q. If we go on, please, to page 32 of your statement, you
  21     speak there of the effects of the creation of the UBHT
  22     in 1991 on aspects of the delivery of paediatric cardiac
  23     surgical services.
  24        In general, what difference did the creation of
  25     the UBHT have on your involvement with the management of

   1     that service? To what extent were you distanced from
   2     it?
   3   A. I think in general, "distance" is the correct term, in
   4     so far as I think it did create, in general terms,
   5     distance. I think that was only countered by the fact
   6     that broadly speaking we were the same officers and the
   7     same professional staff divided into purchasers and
   8     providers. So there was still some ability to
   9     understand ourselves readily, even though we were
  10     carrying out new rules, if I make myself clear.
  11   Q. From the point of view of access to data about outcomes
  12     or clinical standards, did the creation of the UBHT make
  13     any difference?
  14   A. I think the answer is, not a lot, in so far as we have
  15     mentioned already, the complexity of pursuing equality
  16     of standards was so different, so I suppose the answer
  17     might be that I think the distances might have perhaps
  18     delayed our shared understanding of anything that might
  19     be coming out of the complexities, but again, I am
  20     generalising, really, sort of rather widely, because
  21     certainly in aspects of adult cardiac services, I think
  22     we shared fairly readily information and concepts around
  23     quality and standards.
  24   Q. We will come on to the subject of quality and audit
  25     shortly, but the purchaser/provider split of which the

   1     creation of the UBHT was a part was obviously intended
   2     to introduce competition, at least to an extent, within
   3     the NHS.
   4        Do you think it succeeded in doing so in the field
   5     of cardiac services?
   6   A. No.
   7   Q. Because ...
   8   A. Because I suppose the ready capacity to consider any
   9     other service as being in any way better was very
  10     limited, and the ability to make changes to another
  11     location depended on that location having the capacity
  12     to give you the services, which I think was not the
  13     case. Most centres were fairly full in terms of the
  14     capacity that they were already providing. And I think
  15     because of the uncertainties, as I said, in particular
  16     about whether anyone else might be considered better,
  17     the absence of any firm information that that was the
  18     case. There were attempts, for instance, I know, to try
  19     and understand costs for some adult procedures in
  20     different locations. There were some differences of
  21     costs. I think understanding why they were different
  22     was quite complex and readily thinking that somewhere
  23     was cheaper did not always mean that you were going to
  24     get the same service.
  25   Q. So there were difficulties about other centres taking

   1     cases; there were difficulties in making cost
   2     comparisons and there were difficulties in making
   3     comparisons about standards.
   4        One view that might be presented about the effect
   5     of attempting to introduce competition between units is
   6     that it would create an obvious incentive for
   7     a purchaser that was concerned about its standards, say,
   8     to withhold that information or to minimise the flow of
   9     information to a purchaser.
  10        To what extent do you think that might have been
  11     a factor in relationships with the Health Authority in
  12     the field of cardiac services?
  13   A. I think earlier you said the "purchaser", I think you
  14     meant the provider, at the time, was withholding
  15     information. I do not think it was a very strong
  16     factor. I did, on occasions, attempt to understand from
  17     colleagues in districts in the South West who were using
  18     some other centres if they were doing so on any rational
  19     basis or knowledge of difference of quality and they
  20     said not. It was merely in these particular instances
  21     costs-driven. There was some cost advantage in going
  22     elsewhere.
  23   Q. Why would that have a bearing on the pressures or
  24     absence of pressures on clinicians within the provider
  25     when they were considering what data, information,

   1     should be released to you?
   2   A. Probably very little. I think from another point of
   3     view, I think in my evidence I report attempts by myself
   4     to get information on aspects of quality from three
   5     other provider centres from which I knew other Districts
   6     in the South West region obtained cardiac services.
   7     That was the Brompton, Southampton and Oxford. I did
   8     eventually get some information from the Brompton and
   9     some from Southampton, but none from Oxford. My pursuit
  10     of sources from Oxford seemed to imply that that sort of
  11     information was not readily available and therefore
  12     I find it very difficult to know how people made
  13     judgments about the need to make purchases from Oxford,
  14     for instance.
  15   Q. Just to clarify one thing, you have mentioned already
  16     some cost influences in so far as you have already
  17     mentioned that the position of the special health
  18     authorities may have been a factor?
  19   A. Yes.
  20   Q. To that extent, were there cost pressures influencing
  21     referral?
  22   A. Yes. As we addressed this morning, yes.
  23   Q. Would the creation of the Trust after 1991 have
  24     accentuated that form of cost competition in judging
  25     referrals, or not?

   1   A. Yes, I think it did accentuate that one of the changes
   2     and benefits of the changes in the Health Service was to
   3     make costs data more available and more detailed and
   4     defined, so that it allowed for consideration of change
   5     of services.
   6   Q. If we turn over the page to page 33, a small point at
   7     paragraph 7. There is, I think, a typographical error
   8     in (i) in that you talk there about "probable operable
   9     incident cases", but if we look at the letter itself to
  10     be found at UBHT 38/399, that is a letter to Mr Wilson
  11     of the Regional Health Authority, it refers to table 1
  12     showing various information about volumes and rates for
  13     interventions.
  14        If we turn over the page, please, we see there
  15     what I think must be the true and accurate wording
  16     "probable operable incidence of cases."
  17        Is that correct?
  18   A. Yes, I think it is, yes.
  19   Q. So the statement would need to be amended to refer to
  20     that?
  21   A. Yes.
  22   Q. The reason I draw that up, Dr Baker, is that as it
  23     stands, I would have asked you about what the meaning of
  24     "probable operable incidence of cases" is, but as it is
  25     I think it is probably unnecessary.

   1   A. Thank you very much.
   2   Q. If we turn to your statement, we see that at page 33
   3     you made the point that congenital heart disease was
   4     considered by you -- I am sorry, I am looking at
   5     page 32, paragraph 5, under the heading of
   6     "Interventions of uncertain benefits to cost", and that
   7     there was uncertainty as to the merits of particular
   8     procedures if assessed in those terms.
   9        Is it right to say, however, that the contracts
  10     which you placed for children's heart services never
  11     attempted to regulate the type of procedure or to
  12     control them in terms of such an assessment of which
  13     were the most cost-effective or efficient services to
  14     purchase?
  15   A. That is correct.
  16   Q. And is that a contrast, then, of the situation in adult
  17     surgery?
  18   A. Yes, to an extent. I think we were there, in adult
  19     surgery, talking about an approach to coronary heart
  20     disease through bypass grafting which was a known
  21     effectiveness, and some uncertainty as to the
  22     comparative merits of alternative approaches, as
  23     angioplasty, and we were more confident, I think, in
  24     making sure we were resourced actively, the effective
  25     intervention.

   1   Q. So there was an active role played by the authority
   2     there in shaping different types of interventions which
   3     was not the case in terms of children's services through
   4     what, through a greater uncertainty as to what was
   5     effective or ineffective?
   6   A. Yes. There was adequate knowledge in the medical
   7     literature about the evaluation of approaches in adult
   8     surgery which was not the case in children's surgery.
   9     That, coupled with clinical advice, made us more certain
  10     about what we were purchasing in adult services.
  11   MISS GREY: Dr Baker, I would like, if I may, to turn to the
  12     topic of audit, but that may be a convenient moment to
  13     break for either 10 or 15 minutes, according to what
  14     would be most convenient.
  15   DR BAKER: That is most kind of you, but I am happy to
  16     continue, if that is your wish.
  17   THE CHAIRMAN: My wish is that you be comfortable and
  18     in the light of that, shall we take 10 minutes? That
  19     means just before 10 past 2.
  20   (1.57 pm)
  21               (A short break)
  22   (2.10 pm)
  23   MISS GREY: Dr Baker, before we break, I was saying that
  24     we would turn to the topic of audit. If we turn to
  25     page 36 of your statement, that is where these items are

   1     first addressed.
   2        In particular, at the bottom you talk about the
   3     Regional Hospital Medical Committee of the South West
   4     Regional Health Authority publishing a regional approach
   5     to medical audit and recommending that there should be
   6     audit committees in all district health authorities.
   7        If we then turn over the page, we see the result
   8     of that at a District level with a request for the
   9     Medical Information Working Group to consider the
  10     establishment of the Medical Audit Advisory Committee
  11     and you say that the group responded positively.
  12     I think the document in question in fact suggests that
  13     the Medical Information Working Group itself would be
  14     well placed to take this matter forward, at least in the
  15     first instance; is that right?
  16   A. Yes, that is correct.
  17   Q. After that, was a further committee established within
  18     the District or were matters somewhat overtaken by the
  19     creation of the purchaser/provider split in 1991?
  20   A. I do not think there was any further committee within
  21     the District. I think the Trusts set up their own
  22     arrangements.
  23   Q. So from the point of view of the District, what was
  24     its role or responsibility in audit, if any, from 1991
  25     onwards, after the creation of the UBHT and the

   1     purchaser/provider split?
   2   A. Formerly, the requirement lay with the Regional Health
   3     Authority and its support directly with Trusts on
   4     audit. I think health authorities were interested in
   5     audit in so far as it was a way of considering the
   6     heading "Quality" in contracting terms, and I think
   7     those of us in public health medicine had a professional
   8     interest in this tool, providing information on quality.
   9   Q. That is something that you, for instance, refer to in
  10     paragraph 8, when you refer to your own role as
  11     a representative of the Faculty of Public Health
  12     Medicine on the Academy of the Royal College's committee
  13     on medical audit?
  14   A. Yes.
  15   Q. But formerly speaking, it would be correct, would it
  16     not, to say that in 1991 it was the regions who were
  17     responsible for allocating monies that had been
  18     specifically earmarked for "medical audit" as it was
  19     then called and that the District's involvement was, as
  20     it were, indirect through the contracting mechanism?
  21   A. Correct.
  22   Q. And did that position change at a later date?
  23   A. Yes. It changed from the financial year 1994/95 when
  24     the funding arrangement changed and the funding which
  25     had formerly been separately identified by the regions

   1     became part of the general allocation of funding to
   2     district health authorities.
   3   Q. And from that point, they took responsibility, did they
   4     not, for ensuring that audit formed part and parcel of
   5     the standards and processes they were monitoring as part
   6     of their contracting arrangements, rather than being
   7     a matter separately supervised by regional authorities?
   8   A. Yes. I think your description is correct. I am not
   9     sure about the formality of the handover, but as you
  10     describe things, I think in practice that is what
  11     happened.
  12   Q. My attention is drawn to two circulars from the NHS
  13     Executive, firstly EL 95/24, 28th February 1995, dealing
  14     with the creation of the new health authorities, and
  15     secondly, EL 95/103 of 4th October 1995, dealing with
  16     the new health authorities and the clinical audit
  17     initiative, outline of plan, monitoring arrangements.
  18        Those circulars, which will clearly be made
  19     available, detail more precisely the arrangements that
  20     were implemented as a result of the creation of Avon
  21     Health and its responsibilities for audit.
  22   A. Thank you.
  23   Q. If we turn on to paragraph 4, please, you speak there
  24     about the group responding positively but the
  25     development of audit locally and nationally being slow

   1     in general.
   2        What were the obstacles standing in the way of the
   3     development of audit?
   4   A. I think the main one was the feeling that audit was
   5     going to become some form of inspectorial management
   6     tool of professional practice. I think, in general, the
   7     medical profession, and possibly others, closed ranks to
   8     some extent to take ownership of this process to try and
   9     accept it as something which was educational and related
  10     to training and practice in that way, rather than a more
  11     general approach to quality assessment.
  12   Q. You speak about enthusiasts for audit standing out by
  13     exception: radiologists, anaesthetists, surgeons.
  14     Did you mean individuals within those professional
  15     groupings, or did you mean that those professional
  16     groupings were particularly ready to support audit?
  17   A. I think it was both. I think there was evidence that
  18     the Colleges for these groups had individuals within
  19     them who were quite enthusiastic about audit and their
  20     guidance and development of audits centrally from their
  21     colleges became readily available, and therefore it was
  22     not a surprise that on the ground, in Bristol for
  23     instance, one would find radiologists who had advanced
  24     audit in their own practice.
  25   Q. That merely suggests that there were individuals who

   1     were following College guidance. Is there any
   2     particular reason why these three professional groups
   3     would be particularly advanced?
   4   A. I hesitate to suggest that audit is more easily applied
   5     where there are more routine procedures to in fact
   6     audit. I would not want to belittle in any way the
   7     practice in these specialties, but I think probably it
   8     is true that where there is a larger volume of repeated
   9     activity, then audit is facilitated more so than where
  10     that is not the case.
  11   Q. You talk about expressing your concerns about slow
  12     progress to Dr Trevor Thomas. If we look at that
  13     letter, it is to be found at HA(A) 34(14).
  14        You say:
  15        "Following our brief chat on the progress on (or
  16     lack of progress on) medical audit within the UBHT", you
  17     would like a further opportunity to talk. You talk
  18     about this being an area of "considerable suspicion and
  19     defensiveness".
  20        What had been the experience that prompted the
  21     writing of that letter?
  22   A. I am sorry, can I see the date of the letter?
  23   Q. Yes, I am sorry, 27th December 1991.
  24   A. I was an observer to the Medical Information Working
  25     Party and its transition into the District Audit

   1     Committee, and my recall would be that it would apply to
   2     discussion and comments that I heard from Dr Thomas and
   3     others at that time. And perhaps the feeling that we,
   4     certainly in public health medicine, if not other
   5     officers and purchasers, could not be party to audit
   6     either in terms of understanding it or supporting it.
   7   Q. Did you get a response to those concerns?
   8   A. I do not recall having a written response; I think it
   9     was by way of possibly reinforcing a view following
  10     a discussion. I knew Dr Thomas well and I think
  11     probably I was attempting to put down a marker.
  12   Q. That letter discusses the UBHT generally. Again,
  13     generally looking at the UBHT over the following few
  14     years, what was your experience of dealing with audit
  15     related issues with the UBHT as compared to other Trusts
  16     within the District, other Trusts with which you might
  17     have had dealings?
  18   A. I think there were some differences. The differences
  19     follow the pattern of -- in the way in which we have
  20     looked at UBHT earlier today. That was a pattern in
  21     which there was considerable devolution of
  22     responsibility to the clinical directorates and a sort
  23     of federation of clinical directorates working in UBHT
  24     which itself was a very large organisation.
  25        That contrasted with the other Trusts which were

   1     smaller and where that philosophy perhaps was not
   2     followed through so thoroughly.
   3        So there was a contrast around audit in the same
   4     respect, in that audit had found its way down to the
   5     individual clinical directorates and the individual
   6     clinical directorates determined the course of the
   7     development of audit largely, with the Audit Committee
   8     being I think a fairly low-key committee.
   9   Q. You mean the Audit Committee of the UBHT?
  10   A. Correct. Whereas in some of the other Trusts the Audit
  11     Committee played a more managerial role.
  12   Q. What impact do you think that greater freedom at
  13     Clinical Directorate level had upon the development of
  14     audit within the UBHT as compared with other Trusts?
  15   A. I think it was mixed. I think I have alluded to the
  16     sensitivities of the professions with regard to the use
  17     of audit and I think that one of the things that had to
  18     be overcome was this sensitivity and allowing the
  19     professions to feel comfortable with audit and to be
  20     actively involved in its development and use.
  21        So I think in that sense one could argue that
  22     UBHT's approach, which was in parallel to its approach
  23     to the provision of services in general, allowed that to
  24     happen, allowed engagement at the operational hands-on
  25     level.

   1        I suppose the counter-weakness to that was that
   2     where one wanted co-ordination of competition for
   3     limited resources for audit assistants, some perhaps
   4     prioritisation of areas for audit, then there was not
   5     a ready mechanism for that taking place.
   6        The counter would be to say that in my experience
   7     of some audits with other Trusts, where the Audit
   8     Committee masterminded arrangements more so, at least
   9     from a purchaser point of view that could seem to be
  10     over-controlling and exclude to some extent our ability
  11     to make contact with clinicians to talk about audit
  12     areas.
  13   Q. If one looks at cardiac services only, you had
  14     a particular interest in the effectiveness of CABG
  15     procedures and clearly took an active interest in
  16     auditing of that process; is that correct?
  17   A. Correct.
  18   Q. In relation to children, are you in a position or did
  19     you take any interest or give any scrutiny to the
  20     question of audit of surgical activity for the over 1s?
  21   A. No, I did not.
  22   Q. So are you in a position to help us upon what scrutiny
  23     or what audit was taking place of paediatric cardiac
  24     surgery within the UBHT at this time?
  25   A. No.

   1   Q. If we turn to the table of the figures that were made
   2     available to you, we see that at page 44 you set out --
   3   A. I am sorry, could I come back? I said "No" then, but on
   4     page 39, paragraph 18 of my statement, within the time
   5     period of the Inquiry I do make comment upon the audit
   6     taking place between May 1995 and January 1996, so it
   7     was not quite correct to say "No" so completely with
   8     regard to auditing paediatric surgery, both over 1 and
   9     under 1.
  10   Q. I am grateful. In fact, perhaps to follow up those
  11     references, it would also be right to note if we look at
  12     paragraph 15 of your statement, again at that page --
  13     page 39 -- you report there the monitoring of various
  14     services and you report there on the audit reports:
  15     these are also references to data which was made
  16     available in late 1995, in so far as you are reporting
  17     upon the provision of the audit report for 1994 to 1995?
  18   A. Correct.
  19   Q. Made available, I think if we look at those documents,
  20     in late 1995. Those documents, I think, again is this
  21     right, will relate only to adults?
  22   A. Correct.
  23   Q. If we turn then to page 44, that sets out a reference
  24     to returns going up to 1988 when you were provider of
  25     data.

   1        If we go over the page, page 45, the next
   2     information that you were provided with was in 1992.
   3        It would appear, looking at your statement, that
   4     between the presentation of this data in 1992 and the
   5     1994/95 data that you have referred to at paragraph 18,
   6     page 39, the material you have just referred to, you
   7     were not provided with any data as to outcomes in the
   8     paediatric cardiac surgical unit within the BRI?
   9   A. Yes, that is so.
  10   Q. Looking at the contracts that were in place at the
  11     time, the first contract that was first put in place is
  12     to be found -- if we could look firstly at the witness
  13     statement of Miss Evans, WIT 159/48, if we rotate that,
  14     that is a summary of the contents of the various
  15     contracts that were made with the district authority
  16     during the period with which we are concerned and the
  17     clinical audit standards that were there set in: did
  18     they include any requirement, to the best of your
  19     recollection, for the provider to provide any figures
  20     for mortality?
  21   A. Yes, they did, I think. Initially, the first
  22     specification for contract in 1991/92 did carry
  23     a requirement for various aspects of the product of
  24     audit, including 30-day post-operative mortality. It
  25     was unspecified, but I think it was linked to other

   1     matters which suggested that we were thinking about
   2     adult activity.
   3        Then I think subsequently both in terms of our own
   4     reasoning and with advice that we received from others,
   5     we realised we had been over-ambitious in what we were
   6     asking for in that first contract.
   7        Subsequently, those aspects of quality were
   8     rephrased in various ways and moved in general terms
   9     more to a requirement for audit to be taking place
  10     rather than having the expectation that we could be
  11     provided with precise information on different aspects.
  12   Q. So the first contract was, therefore, atypical, in that
  13     it provided specifically for 30-day mortality figures to
  14     be provided, whereas the others were expressed in more
  15     general terms?
  16   A. That is correct, yes.
  17   Q. So if we look again at page 45, we can turn up the
  18     tables for themselves at HA(A) 113/36, this is an
  19     example of a series of tables that was presented.
  20     Specifically we can look at page 39.
  21        Would that have been in response to the
  22     contractual requirement under the 1991 contract to
  23     provide 30-day mortality figures, or was this separate
  24     data provided?
  25   A. I think the answer is separate. This data came to my

   1     notice because it was passed on by the Director of
   2     Public Health, Dr Morgan, from a meeting of his
   3     colleagues, Directors of Public Health and the Regional
   4     Director of Public Health in the South West region, at
   5     which Mr Wisheart had presented information regarding
   6     children's surgery and adult surgery. That is how
   7     I received this documentation, so I think there was no
   8     link that I was aware of with the contracting
   9     requirement.
  10   Q. When you received it, did you review this
  11     documentation?
  12   A. If "review" means that I looked at it, yes, and
  13     considered what was there.
  14   Q. You say it was noted for planning and audit, and in
  15     brackets "(adult purposes)", but if we remain with this
  16     table, the "open correction 1992 under 1 year of age",
  17     and just scroll down a little further, we see there that
  18     there is a figure for hospital deaths within 30 days
  19     given as being 13 within the UBHT and the overall
  20     mortality rate, I think, is expressed in brackets,
  21     23.2 per cent.
  22        There is a little asterisk, a star against that.
  23        If we scroll down a little further, there is there
  24     an observation "(* without neonatal switch, 15.7)".
  25        Do you recollect looking at that table at the

   1     time?
   2   A. I do not recollect doing so, no.
   3   Q. Do you have any recollection, therefore, of whether or
   4     not there had been, or there was raised by such a table,
   5     any interest or conclusions concerning the neonatal
   6     switch programme?
   7   A. There certainly were not in the comments on the
   8     documents written by Dr Morgan. I think the brief
   9     comments I interpreted to mean comments on the adult
  10     data being presented. I do not recall any verbal
  11     comments from Dr Morgan at the time, either.
  12   Q. It is just that looking at this document, one might have
  13     thought that the author saw a reason to exclude the
  14     neonatal switch results and obviously if one scrolls up
  15     towards the top line, it is apparent that there were
  16     11 transposition of the great arteries and five hospital
  17     deaths.
  18        Looking at that table, would it not suggest to you
  19     a concern or put any reader on enquiry as to what
  20     exactly the programme for the neonatal switch was and
  21     what, if any, its implications were?
  22   A. Yes. I agree. I certainly agree with that view now.
  23     I cannot recall or report a sharing of that view at the
  24     time.
  25   Q. You cannot recall or report a sharing of that view at

   1     the meeting Dr Morgan reported to you, and you yourself
   2     do not recollect having such concerns or thinking about
   3     such a matter when you yourself reviewed the tables?
   4   A. That is correct.
   5   Q. If we go back to item 4 on your table at page 43, you
   6     refer there to the interim report of the Working Party
   7     on neonatal and infant supra-regional cardiac surgical
   8     units, and you say it was noted for planning purposes.
   9        What exactly does that mean in terms of what you
  10     did with it when you received it?
  11   A. I think it means that it was general intelligence; that
  12     comment on action qualified by the word "historical" is
  13     me trying to recall what part it played at the time, and
  14     I have used that expression "noted for planning
  15     purposes" because it was planning alongside this service
  16     which was my essential interface. Possibly there to use
  17     the expression of "general intelligence" might be more
  18     appropriate.
  19   Q. Can you recollect having any discussions about the
  20     content of this report with any clinicians at Bristol?
  21   A. Not clearly, no.
  22   Q. Does it follow from that and from the comment that you
  23     have put, the note you have put, that it was "noted for
  24     planning purposes", that when you read it at the time,
  25     it did not suggest to you that there was any reason to

   1     be put on enquiry as to the outcome or standards of the
   2     unit at Bristol or elsewhere?
   3   A. No, that is correct. I hesitate to say "not clearly" to
   4     the former question, because in so far as I was in
   5     contact with either clinicians or other officers
   6     concerned with cardiac services, I may or may not have
   7     made mention of this interim report. Somebody obviously
   8     provided me with a copy and I am afraid I cannot help
   9     you as to where that came from.
  10        So in that sense, it was general intelligence.
  11        I can certainly say now, at this stage, that the
  12     view I would have is what essentially the report says
  13     and that is that Bristol and Newcastle, I think it was,
  14     had no throughput and needed to increase their
  15     throughput, seemingly in the expectation that if they
  16     did, the apparent pattern of 30-day mortality would
  17     change for the better. But I cannot, I am afraid, help
  18     you in saying that I thought that clearly at the time.
  19   Q. If one looks at the report itself -- UBHT 62/579, there
  20     we have the first page of it. If we go in particular to
  21     page 585 first, we can see there the conclusions that
  22     supra-regional funding has brought benefits. Perhaps we
  23     ought to go back a page to get the full thrust. If we
  24     go to 584, we see there, if we go down to the bottom of
  25     the page, "mortality, 30-day hospital", the conclusion

   1     that there is a tendency for mortality to be high
   2     anywhere the units performing the smallest number of
   3     cases in the group of infants undergoing open heart
   4     surgery under 1 year of age. That is figure 3.
   5        If one goes to figure 3, that is page 589.
   6        Then there are a series of mortality rates
   7     expressed as "confidence interval", 70 per cent
   8     confidence limits.
   9        If one matches the number of operations said to be
  10     performed by each centre against those limits, it is
  11     possible to work out which of those centres is Bristol
  12     and to see that it is that with the highest mortality.
  13        That, of course, has to be set with the second
  14     part of that sentence back at page 584, where the point
  15     is made that the same pattern does not appear to be true
  16     of those over the age of 1.
  17        Nevertheless, it would appear, if we stay with
  18     page 589, that here is a centre where the mortality
  19     rates appear to be significantly higher than those of
  20     other centres.
  21        Looking at that report now, is there anything
  22     there that you would feel warranted action on your part
  23     or the beginning of any inquiry or investigation?
  24   A. No, in the context of what I felt were my
  25     responsibilities at the time. Yes, if you are asking me

   1     in a general professional sense. I do not think you are
   2     asking me that.
   3        But I think also, as you have indicated in the
   4     text we have seen already, I think the text says that
   5     this pattern was not unanticipated and indeed, the rest
   6     of the report, as I said, encourages improvement towards
   7     improved mortality in low throughput centres by
   8     increasing throughput.
   9   Q. Can I just clarify with you what you mean by the
  10     difference between "no" in the sense of your
  11     responsibilities at the time but "yes" in a more general
  12     professional sense. What is the distinction you are
  13     expressing?
  14   A. I meant "no" in so far as I did not feel involved in
  15     this respect in the supra-regional service for the
  16     under 1s, and "yes" in the sense that if you are asking
  17     me now if I could consider this as something to be
  18     explored and understood better, then, yes, I could say
  19     "yes" to that professionally.
  20   Q. When Sir Terence English was asked about this
  21     document -- and of course you will recall that he was
  22     then a member of the Supra Regional Services Advisory
  23     Group -- he expressed the view that this data -- I am
  24     talking about the report as a whole -- led him to have
  25     concerns.

   1        He said that he knew that Professor Browse knew
   2     his concerns, but he felt, quoting:
   3        "I think he did not feel any need to take them
   4     further forward and indeed should not have done unless
   5     I specifically asked him to, and I did not."
   6        He was asked the question:
   7        "Because he left them with you?
   8        Answer: Yes.
   9        Question: So it was, as it were, your
  10     responsibility?
  11        Answer: Correct.
  12        Question: And you had expressed them orally to
  13     Dr Halliday but not otherwise?
  14        Answer: Right.
  15        Question: And never, it seems, from what you have
  16     said, thereafter expressed those concerns?"
  17        He answered: "That is right."
  18        Then he was asked the question by Mr Langstaff:
  19        "Do you think perhaps that you ought to have done
  20     so?"
  21        The answer was:
  22        "I think it is a difficult question. I think that
  23     I probably should have written at least to the Chairman
  24     of the group, Sir Michael [the Chairman of the Supra
  25     Regional Services Advisory Group] formally about it.

   1     I suspect that probably that is what I should have
   2     done."
   3        So there was the view from Sir Terence English
   4     that the data in that report did warrant some further
   5     action on his part. What were the differences, as you
   6     perceived them, if any, between your position as
   7     a recipient of that report and that, say, of
   8     Sir Terence?
   9   A. I suppose the obvious one was the responsibility in
  10     relation to the service. Did you say he was a member of
  11     the Supra Regional Services Advisory Group and involved
  12     in the delivery of that service?
  13   Q. Yes.
  14   A. I did not have any responsibilities of that nature to
  15     this service for under 1s. I think that would be my
  16     first consideration.
  17        I think the second difficulty I have as an
  18     observer of this exercise in designation and delivery of
  19     services is just what in fact the report reflected: that
  20     this was an attempt to develop a response to children
  21     with congenital heart defects through the designation of
  22     centres and concentration of skills and in that sense,
  23     it had a developmental aspect to it. One of the factors
  24     which would be appropriate in that development would be
  25     the volume of service which allowed the development of

   1     appropriate skills, and when you consider that behind
   2     these figures here we are talking about a considerable
   3     number of procedures, as you have displayed an earlier
   4     table, so that the number of procedures for different
   5     defects is in fact quite small, with considerable
   6     variation in outcome, then that is a further
   7     complication I think to making the assessment as to
   8     whether a service is providing satisfactory development
   9     or not, really.
  10   Q. You make a point about the complexity of making that
  11     assessment. You have given us details of those problems
  12     of interpretation at page 45 of your statement.
  13        Is there a general point relating to those points
  14     to be made about your level of expertise as a recipient
  15     of data such as the report we have been looking at?
  16   A. Yes. I think in my position as a service consultant in
  17     public health medicine, I had an interest in and
  18     obviously a responsibility for cardiac health and
  19     related services in general, so it was an area in which
  20     I was interested. But I have not got the expertise or
  21     resource to contemplate the forms of analysis that were
  22     being required to understand aspects of what we have
  23     been talking about, of understanding the appropriateness
  24     of comparing outcome, mortality rates between different
  25     centres, et cetera.

   1   Q. You have told us that as a matter of historical record,
   2     when you received this report it did not put you on
   3     enquiry, as it were, that there was anything further
   4     that required to be investigated. It may be that that
   5     is linked to the point you have just made about
   6     expertise. Perhaps you would like to comment on that
   7     supposition?
   8   A. I think it does summarise two things. I read this
   9     report. I think the copy you have has various
  10     annotations on it, as I attempted to understand aspects
  11     of it. It posed various questions and therefore it did
  12     work in terms of providing some intelligence and in
  13     a sense the overall message that here in Bristol was
  14     this supra-regional service which needed to improve more
  15     so, by improving its throughput.
  16        I do not think my expertise, time or interests in
  17     this particular aspect of cardiac services allowed me to
  18     take it any further.
  19   Q. What information or assistance could you have had to
  20     enable you to analyse results in a form that was
  21     meaningful to you as the representative of a purchaser
  22     of services?
  23   A. I think it only could possibly have come from some sort
  24     of contact with the Supra Regional Services Advisory
  25     Group itself. That would have been the only depository

   1     of expert thinking around this issue that I would have
   2     been aware of. I am saying that now, as you are asking
   3     me this question.
   4   Q. What about, say, other expert clinicians?
   5   A. I would not have readily thought in terms of turning to
   6     other expert clinicians, no.
   7   Q. I am thinking perhaps of the Royal Colleges or members
   8     of the Society of Cardiothoracic Surgeons, in general,
   9     other consultant cardiothoracic surgeons. Would they
  10     have been a source of information or assistance to you
  11     at the time, if you had called upon them?
  12   A. Obviously they could have been. You are stretching me
  13     into an area where I have not thought about this before
  14     and certainly did not think about it at the time.
  15     I think now, if you are asking me to answer this
  16     question, I would probably have turned to some academic
  17     department to at least help set the framework in which
  18     these sort of issues could be thought through, perhaps
  19     more so than a clinical resource.
  20   Q. We have talked about the Audit Commission report in
  21     1997 on the difficulties of purchasing specialised
  22     services at least in part because of gaps in information
  23     between the purchaser and the provider.
  24        What do you think now can be done to lessen those
  25     information imbalances?

   1   A. I think we have touched on several aspects of that,
   2     really. I think it needs some consideration of the
   3     expected product of cardiac surgical, cardiological
   4     procedures in terms of standards of outcome, both in
   5     terms of what is termed "safety" in terms of short-term
   6     outcome, and in terms of overall benefit from longer
   7     term outcomes.
   8        It probably needs some collection and integration
   9     of data through some agreed central process with all the
  10     considerations that I have listed here in paragraph 27
  11     of the necessary standardisation for all the matters
  12     I have mentioned, without going into detail about them.
  13     I think it is a very complex exercise. One can only
  14     consider that it can only be best handled by that
  15     collation of data in some well-defined standardised way
  16     being interpreted, again, in a well defined and
  17     acceptable manner.
  18   Q. Moving forward through your statement to page 60, you
  19     deal there with, as I understand it, the point at which
  20     you were made first aware of concerns about the services
  21     at the cardiac unit at the Royal Infirmary. Is that
  22     a correct understanding of your evidence about concerns?
  23   A. Correct.
  24   Q. You mention at paragraph 2 that you received a copy of
  25     the report from Mr de Leval and Mr Hunter on

   1     24th February. Were you able from the documentation you
   2     now have available, to identify who sent that to you?
   3   A. I am not able to.
   4   Q. Someone within the UBHT? Or do you not know?
   5   A. I do not know. I think it is most likely from somebody
   6     in the UBHT and as I indicated earlier, I was in contact
   7     with long-standing colleagues who may have provided me
   8     with a copy of this report, but I have no evidence, I am
   9     afraid, to indicate from whom it might have come.
  10   Q. Because, by the time you received the report, in fact,
  11     you had already been making enquiries of the UBHT,
  12     having been made aware of this issue initially by
  13     Miss Pamela Charlwood; is that right?
  14   A. Things were happening at about the same time.
  15     I certainly can recall I was aware that there were
  16     concerns about paediatric cardiac surgery and two
  17     experts had been invited to come and advise UBHT, so
  18     I knew the nature of that enquiry was taking place. It
  19     was in anticipation of that, I think, that I received
  20     the report. I think it is most likely, although
  21     I cannot be in any way certain, that it was probably
  22     from Mr Wisheart that I received a copy of the report,
  23     given the way in which I have described that he was one
  24     of the persons I had contact with.
  25        That was happening at the time that I was asked by

   1     Pamela Charlwood to enquire as to what was happening and
   2     in the knowledge that the enquiry was taking place, it
   3     seemed appropriate to base my enquiry on the receipt of
   4     the report.
   5   Q. I think I may have implied by an earlier question that
   6     the very first you knew was when you actually received
   7     the report. If I did, I apologise for wording the
   8     question badly. I meant to ask you whether or not your
   9     first knowledge of this dated to the time when you
  10     understood the UBHT had asked for a report to be
  11     prepared and/or was around the date of 18th January
  12     given by Miss Charlwood?
  13   A. Yes. I cannot recall at all, and I have no evidence of
  14     knowing that UBHT had asked for an enquiry. I think
  15     I only picked that up once that decision had taken place
  16     and an enquiry was taking place, or was about to take
  17     place.
  18   Q. You then refer to the report from Mr de Leval and
  19     Dr Hunter. We can see the document that you sent to us
  20     as the one you received when it was sent to you at
  21     74/1457.
  22        That is the title page. Were you aware, until
  23     before recent days -- I mean within the last week or
  24     so -- that there is in fact another version of this
  25     report which we can see at UBHT 61/378?

   1   A. No, I was not.
   2   Q. So it was only within the last few weeks or so that you
   3     became aware of a second version?
   4   A. The last few days.
   5   Q. I think it must follow from that that you cannot help us
   6     as to the circumstances in which one report was amended
   7     and another produced?
   8   A. Only in the light of what I know in the last few days,
   9     but that is common knowledge to both of us, I think.
  10   Q. What I mean is that you had no firsthand involvement or
  11     contemporaneous involvement in the circumstances of the
  12     production of the document we are looking at?
  13   A. Correct.
  14   MISS GREY: Thank you very much, Dr Baker.
  15        Dr Baker, I have asked you questions over a very
  16     long period of time. Is there anything that you would
  17     like to add to assist the Inquiry?
  18   DR BAKER: Thank you. That is kind of you. I feel perhaps
  19     it is a question of emphasis, because it is a point you
  20     brought up in your questioning and that was about the
  21     position after de-designation. I am just giving
  22     emphasis to the state in which district health
  23     authorities found themselves then.
  24        I think as we have reflected this morning, it
  25     might have been very difficult other than for the steady

   1     state to be advised as a way of continuing these
   2     services.
   3        I am just mentioning that as an area where one
   4     might have hoped for more guidance, but in fact that is
   5     what we took forward.
   6   MISS GREY: Thank you, Dr Baker. Before I sit down
   7     and ask whether the Panel have any questions, I should
   8     just mention one thing: we have had provided by
   9     Mr Wisheart a comment on your statement, Dr Baker, and
  10     it relates to page 20 of the statement, if we could just
  11     call that up. It is upon the description of Mr Wisheart
  12     and he writes to the Inquiry, at page 20B, "Key
  13     clinicians: 1 ...:
  14        "Dr Baker states I was an Associate Director of
  15     Cardiothoracic Services within the Surgical Directorate
  16     from 1985 to 1990" and he adds as a matter of detail,
  17     "For the record, I was the first Associate Clinical
  18     Director of Cardiac Surgery from 1990 to 1992. During
  19     the period 1985 to 1990, Mr G Keen was the senior
  20     cardiac surgeon and I held no designated management or
  21     administrative post within the Department of Cardiac
  22     Surgery."
  23        I daresay, Dr Baker, you would accept from
  24     Mr Wisheart that that is correct?
  25   A. Thank you.

   1   MISS GREY: Thank you very much, Dr Baker.
   2   THE CHAIRMAN: Dr Baker, Professor Jarman would like to ask
   3     a question.
   4            Examined by THE PANEL:
   5   PROFESSOR JARMAN: Just one thing, to try and sort out
   6     responsibility. You made it quite clear on a couple of
   7     occasions you said you did not believe that it was your
   8     responsibility to be monitoring the quality for children
   9     under 1s, in the supra-regional services?
  10   A. Yes.
  11   Q. When we saw Dr Gregory, who was the director of the NHS
  12     for Wales, he was of the view that it was actually the
  13     Health Authority who was responsible, and then we saw
  14     Mr Angilley who said that the provision of health care
  15     has always been the statutory responsibility of the
  16     local health bodies, and later on the statutory
  17     responsibility for the provision of health care and
  18     therefore for standards is firmly in the hands of the
  19     local health bodies who provide that service. Mr Steven
  20     Owen was of the same view.
  21        So they had that view that it was in fact the
  22     local Health Authority and you have the view that it was
  23     them.
  24        Later on we have heard from Mr Nix. He seemed to
  25     be of the view that actually it was the local public

   1     health body that had the responsibility for monitoring
   2     the services and we got a similar view from Deborah
   3     Evans as well. So people within the local Bristol area
   4     were of the view that it was the public health.
   5        Do you have any comments upon that?
   6   A. Yes, thank you. I think first of all, it is a question
   7     as to whether people in making those comments were being
   8     clear that they were talking about services in general
   9     or whether they were being particularly cognisant of the
  10     fact that some part of this was a supra-regional
  11     service, and I would be slightly surprised if colleagues
  12     in my District failed to make that separation. I cannot
  13     speak for others who you have mentioned.
  14   Q. By "others" you mean the supra-regional services?
  15   A. Other commentators who made these remarks to you, either
  16     surgeons or members from the Welsh Office, et cetera.
  17     I think to try and in a sense discuss this, it is not
  18     clear, the supra-regional service appeared to be
  19     provided and advised upon by the Supra Regional Advisory
  20     Group. I think I am right in recalling that in the
  21     interim report we were talking about earlier, I think
  22     the group does actually there say that they have the
  23     expectation that the audit activity by the group would
  24     continue. I think it is in that document; it might have
  25     been in the other contractual documents that the

   1     department drafted, but somewhere there was the
   2     expectation that audit by the group continued. I cannot
   3     be certain about that.
   4        So I do not feel that during the time of the
   5     Inquiry which we are interested in I feel that I was
   6     directly and immediately responsible for the outcomes in
   7     that service, no.
   8   PROFESSOR JARMAN: Thank you.
   9   THE CHAIRMAN: Thank you, Dr Baker. Mr Brooke?
  10   MR BROOKE: Thank you, sir. Just a few questions.
  11            RE-EXAMINED BY MR BROOKE:
  12   Q. While it is fresh in our mind, Dr Baker, your last
  13     answer to Professor Jarman was that you thought there
  14     was a reference to audit by the Department of Health in
  15     that interim report.
  16        Could we see -- I have it at WIT 74/1086. I think
  17     we see there, seven lines down, "Annual audit of work
  18     performed ..."
  19   A. Thank you, that is what I was thinking about.
  20   Q. Whose note is that in the margin?
  21   A. Mine.
  22   Q. Just a few further points, if I may.
  23        You were asked to look at document HA(A) 117/24.
  24     Miss Grey asked you to look at that document and said
  25     this is a similar date in that it is a note of a meeting

   1     on 15th October 1985, a discussion with regional
   2     specialties, cardiac surgery.
   3        Could you just tell us who the representatives of
   4     the Regional Health Authority are there?
   5   A. Dr Reynolds was the Regional Medical Officer at that
   6     time. Dr Pitman was a consultant in I think it was
   7     called "community medicine" at that time, with the
   8     Regional Health Authority, it would now be "public
   9     health medicine". Mr Lilley I think was a financial
  10     representative and Mr Watts I am uncertain. I think he
  11     might have had a planning role, but I cannot recall.
  12   Q. That is a meeting, is it, between the Regional Health
  13     Authority and the District Health Authority, for what
  14     purpose?
  15   A. I think it was part of the continuing joint approach to
  16     the expansion of cardiac surgery in Bristol, which was
  17     region-led and in that sense, we are here talking about
  18     again the expansion of open cardiac surgery mainly for
  19     adults but taking into account children over the age of
  20     1 year.
  21        The regionally led initiative on that and our
  22     involvement as the district within which the cardiac
  23     centre at the BRI was placed.
  24   Q. Could we go on to page 28 of that document? In answer
  25     to Miss Grey, you were asked about the involvement of

   1     clinicians. You said "My recall is, I do not think we
   2     ever had an indication from the clinicians". We see
   3     there, paragraph 12.1, Mr Keen, who was a cardiac
   4     surgeon, was he not?
   5   A. Correct.
   6   Q. And the cardiologists were going to be invited next time
   7     around.
   8        Then you were asked about a response to a letter
   9     at UBHT 266/5. This is I think your letter, is it, if
  10     you go to the top?
  11   A. I do not know. It says "JB", but ...
  12   Q. It was a response to Professor Dunn speaking of the
  13     needs for neonates.
  14        Anyway, at the bottom of that page you draw
  15     a distinction between a regional specialty and the fact
  16     of Bristol attracting work from other parts of the
  17     region because of its eminence.
  18        Do you see, at the bottom of that page?
  19   A. Yes.
  20   Q. You were then asked by Miss Grey about your letter to
  21     Mr Wisheart. That is at page 30 and I think the
  22     reference for it is WIT 74/400.
  23        If we could look at the top of the page, is
  24     that a letter written from your home address?
  25   A. Correct.

   1   Q. How long had you and Mr Wisheart been colleagues --
   2   THE CHAIRMAN: I took it off the screen for a moment.
   3     It was clear for us to have that.
   4   MR BROOKE: I just wanted to set the letter in its context.
   5     For how long had you been colleagues?
   6   A. Since I came to the District in the early 1980s.
   7   Q. Could you look, please, at the third and fourth
   8     paragraphs of that letter. Maybe they could be
   9     magnified a little:
  10        "At the time of concerns arising ... I wrote to
  11     the UK Society of Cardiothoracic Surgeons ..."
  12   A. Yes.
  13   Q. Does that really sum up your investigation at that
  14     stage, in 1996, into what the state of the data was?
  15   A. Yes. It was 1995/96, I think, yes. Yes, it was, yes.
  16   Q. Why did you write that letter to Mr Wisheart?
  17   A. I suppose essentially because I was a long-standing
  18     professional colleague of his and because he was
  19     undergoing a taxing inquiry by the General Medical
  20     Council, as indeed was Mr Dhasmana, and I felt that he
  21     should be supported by what interpretation of the
  22     circumstances I had which would allow him a fair
  23     assessment.
  24   Q. Do you reproach yourself for writing that letter?
  25   A. Not at all.

   1   Q. Then you were asked about circular 90(9) and how that
   2     circular worked. If we could look at that, it is
   3     HOME 1/221.
   4        This is the circular that replaced the old
   5     HM 61/112, you remember?
   6   A. Yes.
   7   Q. Is it within your knowledge whether that circular that
   8     was issued in 1990 is also used by Trusts in respect of
   9     consultants' contracts that they hold that entitles
  10     consultants to this procedure?
  11   A. Yes, it is my understanding.
  12   Q. You were asked about your function in relation to it.
  13     If we could go, please, down the page and on to
  14     page 226, down the page, we see there, I think, do we
  15     not, that the first step is for the Chairman in a case
  16     involving alleged professional incompetence or
  17     professional misconduct to decide whether there was
  18     a prima facie case.
  19        You are nodding?
  20   A. Yes.
  21   Q. We also see that either the District Director of Public
  22     Health or the Regional --
  23   THE CHAIRMAN: Mr Brooke, just turn your microphone.
  24     By all means stay there, just turn your microphone
  25     towards you.

   1   MR BROOKE: I was just checking I was looking at the
   2     right part. The Chairman has to decide whether there is
   3     a prima facie case and the Director of Public Health has
   4     a stated function in relation to that.
   5   A. Yes, thank you.
   6   Q. Because you had said to Miss Grey that as you remembered
   7     it, you had an advisory function?
   8   A. Yes.
   9   Q. But during the time you were Director of Public Health,
  10     you would have had a stated function?
  11   A. That is correct, yes.
  12   Q. It was then suggested to you that, if we go over the
  13     page, there is provision for a panel of inquiry to
  14     investigate the matter if it is thought that the
  15     Chairman needs such guidance or assistance.
  16        If we look at paragraph 7, we see that that is the
  17     next stage in the procedure, is it not, if the Chairman
  18     decides there is a prima facie case?
  19        Then the Chairman of the authority or the Trust
  20     falls out of the picture and the independent panel,
  21     chaired by a lawyer, takes over?
  22   A. Yes, I believe so, thank you.
  23   Q. Further on the topic of the "three wise men" procedure,
  24     what would happen if one of the three wise men was the
  25     subject of a complaint?

   1        You said that, amongst other things, further
   2     advice would be sought from other wise people including,
   3     you mentioned the Regional Medical Officer?
   4   A. Yes.
   5   Q. Your District was unusual in that being a teaching
   6     District, it would hold the contracts of employment of
   7     consultants; correct?
   8   A. Yes.
   9   Q. But elsewhere throughout the South West region, those
  10     contracts would be held by the region?
  11   A. Yes.
  12   Q. So the experience of dealing with those sort of
  13     problems at a regional level would almost certainly be
  14     considerably greater than the experience at the District
  15     level?
  16   A. That is correct.
  17   Q. You were then asked about Professor Henderson, meetings
  18     over the Welsh matter. Could we look, please, at
  19     page 25 of Dr Baker's statement? That is 74/25,
  20     paragraph 9.6.
  21        At the end of that paragraph, you refer to
  22     a letter from Professor Henderson, written to you,
  23     offering to discuss any matters further. This is in
  24     1987, I think, is it not? You say you did not take up
  25     his offer.

   1        Then if we could look at that letter which is
   2     WIT 74/477, is there anything in that letter to make
   3     assertions about Bristol or criticisms of the standards
   4     at Bristol?
   5   A. No.
   6   Q. Was there any reason that you could see for you to take
   7     him up on his constructive offer?
   8   A. No, not at all. I had known Professor Henderson when
   9     I myself was at a research unit in Cardiff and I think
  10     his felicitations were in part in that direction, and
  11     I saw no reason to take any matter up with him.
  12   Q. You were next asked, I am looking at page 78 of the
  13     transcript, line 19, where your attention was drawn by
  14     Miss Grey to some figures. I have not noted the
  15     reference, but I am not sure it is necessary to go to
  16     it, because it was a drop from 27 to 19.24. You made
  17     the point, according to the transcript, that it would
  18     mean a difference between 19 and 20 and you said at line
  19     19, "So in other words, there would have been one extra
  20     death in Bristol had the implied UK standard applied".
  21     I think you meant there would have been one less death;
  22     I think that is right?
  23   A. Yes, that is correct. Yes, that is right.
  24   Q. Page 90, line 2, you are being asked about
  25     de-designation.

   1        You said: "I felt there was no easy mechanism at
   2     all other than contemplating some very difficult
   3     collaboration between district health authorities in
   4     trying to agree where purchasing might be focused, and
   5     that would be extremely difficult as well. I think, if
   6     you like, the practised approach had been that which was
   7     carried out through designation of 9 centres, and one
   8     could not, from the information available on
   9     de-designation, hesitate to know whether 9 had been felt
  10     to be the right number or too many or too few".
  11        What did you mean by that? Do you have it on the
  12     screen in front of you?
  13   A. No, I do not. I recall that statement. First of all,
  14     there was no information, but I suppose I was adopting
  15     the view that the earlier view of the Department of
  16     Health and the Advisory Group presumably had been that
  17     9 centres would be an appropriate number in which to
  18     give this specialised service, but at least some part of
  19     the interim report suggested that, for instance,
  20     throughput was difficult in some centres, even though
  21     the centres were geographically widespread and were
  22     covering large catchment populations.
  23        So one might suppose that a case could have been
  24     made for having fewer centres and in fact on
  25     de-designation there might have been some concern, if

   1     not danger, that any enlargement of even more centres
   2     would have weakened further the throughput and the
   3     maintenance or development of skills.
   4   Q. Then, at page 91, you say, or you agree, that the fact
   5     of the matter is, 94/95, you continued to commission on
   6     the basis of a steady state.
   7        Would this be a fair description, that you go from
   8     a supra-regional service to a subregional service?
   9   A. Yes.
  10   Q. What about a role for the Regional Health Authority in
  11     that: de-designation and limiting the spread of
  12     centres?
  13   A. I think clearly there would have been a role, because
  14     they have the overview of the districts within their
  15     authority and the arrangement under the internal market
  16     was that they were responsible with Trusts for the
  17     development of services. So I think you are correct in
  18     suggesting that.
  19   Q. You were asked about the curiosity of the Special Health
  20     Authority servicing Devon and Cornwall and that there
  21     was a cost implication to that and that may have
  22     influenced the pattern of referrals as well as the
  23     alma mater point that you made.
  24        What about after the introduction of the
  25     purchaser/provider split? Do you know when those

   1     special health authorities achieved Trust status?
   2   A. I know it was delayed and I know the --
   3   Q. Maybe I can lead you on that: it was 1st April 1994, so
   4     that would have been three years when you still had
   5     special health authorities in London, but UBHT had
   6     achieved Trust status?
   7   A. Yes, and in fact returning to the role of the region
   8     having an overview in this case for adult cardiac
   9     surgery, they were wishing to develop a cardiac centre
  10     at Plymouth to provide more adult services for that part
  11     of the region, and it was my understanding that that was
  12     delayed because the monies spent in the special health
  13     authorities in London needed to return to support Devon
  14     and Cornwall in purchasing their services from a new
  15     centre in Plymouth.
  16   Q. Those dates referred to the three SHAs, Hammersmith,
  17     Brompton and Great Ormond Street.
  18        You were asked about the audit responsibilities
  19     and the two executive letters and no doubt those will be
  20     looked at in detail in due course. I do not know if it
  21     is possible to call them up, but do you know whether
  22     those executive letters were envisaging not merely the
  23     expansion of the functions of the Health Authority, but
  24     the transfer of functions from the soon to be abolished
  25     regional health authorities to the district health

   1     authorities?
   2   A. That appeared to be the case, as described, yes.
   3   Q. You were asked about the interim report in 1989 to the
   4     special Supra Regional Services Advisory Group and you
   5     were asked about what you thought you might have done
   6     about that. We have just had it up on the screen.
   7        So that was a report to the Supra Regional
   8     Services Advisory Group in respect of the supra-regional
   9     service by a sub-committee of the Society of
  10     Cardiothoracic Surgeons; that is right, is it not?
  11   A. Yes, that is right.
  12   Q. What involvement did you have with that?
  13   A. None at all.
  14   Q. We see from your letters that in due course you did make
  15     enquiries of that Society as to their data collection
  16     processes, did you not?
  17   A. Later on, I did.
  18   Q. I think this is the last matter I want to ask you about,
  19     Dr Baker: you were asked about the de Leval report and
  20     which one you received. Then you described what your
  21     involvement was in that, and that you were asked by
  22     Miss Charlwood, and we have seen from her statement that
  23     that was so.
  24        Could we see, please, UBHT 61/293?
  25        That report, the one you received dated

   1     24th February 1995, and then in due course over into
   2     March, I think it is right that you and Miss Charlwood
   3     went to see Dr Roylance, asked questions, got answers,
   4     et cetera.
   5        Can we just look at who was at this meeting on
   6     9th March?
   7        There are representatives of the Regional Health
   8     Authority; is that right?
   9   A. Correct.
  10   Q. Who is there from the Regional Health Authority?
  11   A. The Chairman, Rennie Fritchie; the Regional Director of
  12     Public Health, Dr Scally; Mr John Churchill, Director of
  13     Corporate Affairs.
  14   Q. And from UBHT, several people?
  15   A. The Chairman, Mr McKinley; Mr Graham Nix, the Deputy
  16     Chief Executive; Professor Vann Jones, Clinical Director
  17     of Cardiac Services; Mr Gabriel Laszlo, Chairman of the
  18     UBHT Medical Committee; Dr Hyam Joffe, consultant
  19     paediatric cardiologist.
  20   Q. Are there other people from the Department?
  21   A. Dr Peter Doyle and Isobel Nisbet and Billy Flynn.
  22   Q. Was there anybody there from Avon Health Authority, the
  23     home purchaser?
  24   A. No.
  25   Q. Did you know of this meeting?

   1   A. I did not.
   2   Q. We see that the first item is Miss Fritchie opened the
   3     meeting and welcomed colleagues. She thanked all those
   4     present for attending at such short notice.
   5        We do not need to go into the meat of it, but what
   6     function is the Health Authority exercising at that
   7     meeting?
   8   A. It is exercising its function as the Regional Health
   9     Authority in association with a service taking place
  10     from a Trust within its region.
  11   Q. Is it exercising a supervisory function?
  12   A. Yes.
  13   Q. Is the department exercising a supervisory function?
  14   A. It is possible. It would seem so.
  15   Q. Was Avon invited to that meeting?
  16   A. No -- well, I assume no. I have no knowledge of the
  17     meeting myself.
  18   MR BROOKE: Yes, thank you, Dr Baker. Thank you, sir.
  19   THE CHAIRMAN: Thank you, Dr Brooke, that was helpful,
  20     and just within the allowed time!
  21        Dr Baker, we are very grateful to you for coming
  22     to talk to us today. You have already supplied us with
  23     a great deal of information for which we are grateful.
  24     Should there be any more or anything else you would wish
  25     to bring to our attention, do please let us know or let

   1     us have it, either yourself or through those who advise
   2     you.
   3        May I impose on you for literally a few moments at
   4     most, while Mr Langstaff tells us whatever else we may
   5     need to know before we adjourn for the day.
   6   MR LANGSTAFF: Sir, I trailed yesterday what was going to
   7     happen on Monday, we hope, and next week. That remains
   8     the case, so for once in these hearings I have nothing
   9     further that I need say.
  10   THE CHAIRMAN: I say thank you, Mr Langstaff, not for that,
  11     but for your help more generally.
  12        So we adjourn now and reconvene as is our normal
  13     practice at 10.30 on Monday next. Thank you, Dr Baker.
  14     Thank you, everyone else. Thank you, Miss Grey. Good
  15     afternoon.
  16   (3.33 pm)
  17     (Adjourned until 10.30 am on Monday, 12th July 1999)
  18
  19
  20
  21
  22
  23
  24
  25

   1
   2                I N D E X
   3
   4
   5     DR IAN ALFRED BAKER (AFFIRMED):
   6        Examined by MISS GREY .................... 1
   7        Examined by THE PANEL .................... 127
   8        Re-examined by MR BROOKE ................. 129
   

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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001