Home Page Search Final Report Interim Report Evidence - Transcripts - Witness Statements - Submissions - CCNR Report and associated documents - Statistical Reports and associated documents - Background Papers - Expert Papers Inquiry Seminars About the Inquiry Help		Daily transcripts Back to list of daily transcripts Hearing summary 12th May 1999 Today the Inquiry heard evidence from Dr Bill Reith, Honorary Secretary of Council, The Royal College of General Practitioners. He described the examination for the membership of the College introduced in 1965, which is the assessment of the knowledge and competencies of the general practitioner on completion of vocational training. In 1989 Fellowship by Assessment (FBA) was introduced. It is awarded on the basis of a demonstration of a high level of competence in day-to day work in general practice. Membership by Assessment of Performance (MAP) has recently been introduced and is intended to assess the knowledge, skills, attitude and performance of a doctor in active practice. Dr Reith said these assessments ensure that the College takes a key role in promoting quality of the discipline of general practice. He said that comparable assessments of competency are not currently common to other Royal Colleges. The introduction of Accreditation of Professional Development (APD) is planned to cover continuing education. Answering questions relating specifically to paediatric cardiac problems, Dr Reith confirmed that contact with patients with congenital heart defects would be a rare occurrence for most practices. Therefore a first referral would probably be to a local district general hospital for initial assessment. Referral on to a specialist centre might then be made by the local paediatrician. He went on to say that the College had been unable to identify any information supplied to GPs which highlighted problems in complex paediatric cardiac surgery performance at the Bristol Royal Infirmary (BRI). However, had such information been available, Dr Reith felt that GPs would have found it difficult to interpret such information and would rely on the judgement of the local consultant paediatrician as GPs would not be able to observe patterns of performance against national standard. He highlighted the issue of notification of the GP to the death of one of their patients following surgery, stressing the importance that this should be done in a timely manner to avoid distress and embarrassment.

FULL TRANSCRIPT

   1                       Day 16, 12th May 1999
   2   (11.00 am)
   3   MISS GREY: Good morning, sir. Good morning, Panel.
   4   THE CHAIRMAN: Good morning, Miss Grey.
   5   MISS GREY: Sir, today we have the benefit of hearing from
   6     Dr Reith. Could I ask him, please, to come forward to
   7     the stand?
   8        Dr Reith, I think it has been explained to you
   9     already that we have been taking evidence on oath in
  10     this Inquiry, so could I ask you first, please, to stand
  11     to take the oath?
  12            DR WILLIAM REITH (Sworn)
  13             Examined by MISS GREY:
  14   Q. Dr Reith, you are the Honorary Secretary of the Royal
  15     College of General Practitioners and you have come today
  16     to give evidence on behalf of the College; is that
  17     right?
  18   A. Yes, it is.
  19   Q. If I could just ask, please, for the statement WIT 59/1
  20     to come up on the screen, we should have there the first
  21     page of the statement you kindly submitted to the
  22     Inquiry. Do you have that, Dr Reith?
  23   A. Yes.
  24   Q. If we turn to page 16 of that statement, that is your
  25     signature, I think, at that page?

   1   A. Yes.
   2   Q. So you have come today to talk to that statement and to
   3     help us on that.
   4        You have set out in your statement the work of the
   5     College in general and you have exhibited a number of
   6     documents to it. If we turn to page 20, we will see
   7     there, I think, the charter of the College, and in
   8     particular the purposes, as you would expect, are set
   9     out. At paragraph 2 we see that the object for which
  10     the College is incorporated shall be "to encourage,
  11     foster and maintain the highest possible standards in
  12     general medical practice".
  13        It is then given a number of powers to achieve
  14     that end; is that right?
  15   A. Yes, that is correct.
  16   Q. You have set out, then, in your statement, the number of
  17     steps that the College has taken to seek to deliver that
  18     purpose throughout the years of its existence, and we
  19     can turn back, perhaps, to page 6 of the statement,
  20     where you have started to summarise those. Those are
  21     set out at page 6, and at page 7, and what I would like
  22     to do is to just look at a number of those in a little
  23     bit more detail and look in particular at the work that
  24     the College has done throughout the 1980s and the 1990s.
  25        It might be perhaps convenient to start by looking

   1     at an article which you will be well familiar with,
   2     which appears at page 683 in the bundle. This is the
   3     1993 article written by Sir Donald Irving, as he now is,
   4     about the subject of quality in general practice.
   5        Can I just ask you, that is an article, is it,
   6     that you have come across on a number of occasions, no
   7     doubt?
   8   A. Yes.
   9   Q. What is set out in that article, and it is really
  10     apparent from the very first paragraph, was an analysis
  11     of what you might call the "Achilles heel" of the
  12     profession, variability in quality. Sir Donald said at
  13     the beginning:
  14        "Despite many major improvements, unacceptable
  15     differences in the quality of general practice still
  16     persist today".
  17        If we drop down further in the next paragraph:
  18        "Although in our inner cities unsatisfactory
  19     working conditions are still common, generally we have
  20     to face the fact that where there is poor care, it is
  21     often the result of a practitioner's incompetence or
  22     unwillingness to give the time and attention to provide
  23     a basic service."
  24        Would you agree with the analysis and the summary
  25     of the problems that Sir Donald set out in that

   1     article?
   2   A. I think that there do continue to be variations in
   3     quality. I do think that the situation has improved.
   4     At the time this publication was written, there was no
   5     required entry standard to general practice, other than
   6     at that time the basic medical qualification.
   7     Obviously, the College had been in existence for
   8     a number of years and its examination for membership had
   9     been in existence for a number of years at the time this
  10     was written, but there was no generally recognised
  11     professional recognition that membership by examination
  12     of our College was a requirement to become a general
  13     practitioner, and indeed, no legal requirement either.
  14        What has happened more recently is that the Joint
  15     Committee on Postgraduate Training for General Practice,
  16     which is in effect the licensing authority for general
  17     practitioners, now has a compulsory assessment called
  18     summative assessment which does seek to assess the
  19     competence of those entering general practice.
  20        The College is involved as one of the bodies
  21     involved in the Joint Committee, but the College would
  22     still suggest that its examination for membership is at
  23     a higher standard than summative assessment and is
  24     indeed a more appropriate assessment for a doctor going
  25     into independent general practice.

   1   Q. I think it is right that the College has sought to
   2     suggest that the College's qualification should be
   3     regarded as the norm for recruitment of GPs into
   4     independent practice. Is that something that has been
   5     generally accepted by practitioners across the country?
   6   A. It is patchy. There do seem to be historically some
   7     parts of the country where for younger doctors in
   8     training, it is the norm. They accept that when they
   9     are coming to the end of their training, they will sit
  10     the College examination. That is just accepted.
  11        In other parts of the country, the role of the
  12     College perhaps has been seen as less relevant and there
  13     has been no such encouragement for that. So, again, it
  14     has changed a little. I think also, there are some who
  15     perhaps have seen the College setting itself up as
  16     elitist and not appropriate to do so.
  17   Q. Returning to this 1983 article, it might perhaps be seen
  18     as a major stepping-stone on the way to the process of
  19     evolving more self-conscious standards of practical
  20     competence and skills within a GP's practice, and the
  21     College is obviously working upon those since that
  22     date. Would it be fair to characterise the article as
  23     being an important stepping-stone, or not?
  24   A. Yes. I think the article which was part of a wider
  25     initiative called the Qualitative Initiative which

   1     Donald Irving was one of the key players in moving that
   2     forward from the College, but it was at a time when the
   3     College was increasingly concerned and taking an
   4     increasing interest in improving quality of care for
   5     patients.
   6   Q. Another aspect of the article that, as it were, shines
   7     through it is the analysis that is set out there of the
   8     challenge to the GP's way of practising that may be
   9     faced if the problem of the variability in standards
  10     that is set out in the first paragraphs we have looked
  11     at was not addressed.
  12        We look down the page, perhaps, to the second half
  13     where the test ahead is set out and the author writes:
  14        "For the immediate future, the independent
  15     contractor arrangement will continue", and dropping down
  16     a sentence:
  17        "The government and the rest of the profession are
  18     still of a mind to see whether we have the will and
  19     ability to furnish a future service of high quality
  20     within the present contractor framework. Such generally
  21     favourable conditions can themselves induce complacency
  22     and poor motivation. Therefore our foremost challenge
  23     is to show that we independent contractors are capable
  24     of establishing an effective system of self-regulation
  25     to provide primary and continued medical care of

   1     a standard which will be acceptable and highly
   2     desirable."
   3        He goes on to set out the possible consequences of
   4     failing to grasp this nettle. He talks about -- I am
   5     going to the top of the next column -- that if the
   6     quality issue is not thoroughly and decisively tackled,
   7     then forces outside might move to change the political
   8     consensus that he has identified and that, for instance
   9     in his own profession, specialists were beginning to
  10     look for work outside as well as inside hospitals, that
  11     paediatricians, psychiatrists, geriatricians, were the
  12     best illustrations, but physicians and obstetricians
  13     might also be doing the same, as hospital specialists
  14     expanded outside conventional boundaries.
  15        Then, equally well, there are further challenges
  16     set out, and if we go on down the page a little bit, you
  17     can see in the paragraph beginning "It is against this
  18     potentially unstable background", the passage about
  19     two-thirds of the way down:
  20        "If the policy failed, the government could well
  21     move on to offer patients more choice by loosening the
  22     monopolistic bonds of the referral system so that
  23     hospital specialists could compete with general
  24     practitioners as providers of primary medical care in
  25     our big towns and cities."

   1        Donald Irving was there setting out that
   2     a prospect of a challenge to the GP's monopoly of
   3     primary care in the profession did not respond to the
   4     challenge he had been identifying.
   5        How well do you think that article stands out as
   6     a prediction for what might happen across the next 15
   7     years or so?
   8   A. I think many of the things that are in the article
   9     there, the other practitioners in the field, if you
  10     like, the reference to hospital specialists perhaps
  11     looking to do what is often now called "outreach
  12     clinics", the particular interest in nurse practitioners
  13     and indeed other practitioners being involved, remains.
  14     I think part of that is not just about the quality
  15     issues; I think that part of that is generally people
  16     looking at different ways of working and just generally
  17     seeing if we can provide as good or better a service in
  18     alternative ways.
  19        So, for example, over the years, and indeed,
  20     probably into the future, the scope of work that may be
  21     undertaken by nurse practitioners, for example, will
  22     continue to be examined.
  23        I think that one of the difficulties that any
  24     generalism has in whatever sphere, whether it is
  25     medicine or the law or whatever, is always the one of

   1     the generalist being seen as having particular skills.
   2     The jibe very often is "the jack of all trades and
   3     master of none". What that fails to recognise are the
   4     very real skills required of a generalist. Those skills
   5     are no less real than those of a specialist, they are
   6     just different, but I think they can be articulated.
   7     I think one of the things the College has tried to do
   8     over the years is to articulate those.
   9        I think perhaps the most important skill for the
  10     general practitioner and the role of the general
  11     practitioner in a general sense in that generalism is in
  12     fact being the advocate of the patient, and that is
  13     a role that the generalist is particularly well suited
  14     to undertake, in a way that individual specialists
  15     cannot, because they may be dealing with an individual
  16     patient who may have more than one problem, so they may
  17     be seeing a number of specialists but actually only one
  18     general practitioner.
  19   Q. I think the role of the GP as the advocate of the
  20     patient is something to which we will return on the
  21     subject of referrals and the information GPs have on
  22     that front. Can I ask you, because you have touched
  23     upon it, about the question of the status of GPs in
  24     amongst the medical profession as a whole, because there
  25     is a tension that you referred to between attitudes

   1     towards generalists and attitudes towards specialists.
   2     How have GPs been regarded?
   3   A. I think that has changed, obviously, over time, and
   4     I think that at one time, perhaps round about the time
   5     our College was being set up, that the standing of
   6     general practitioners with their other medical
   7     colleagues was perhaps not all that it might be.
   8     I think that there are perhaps a number of reasons for
   9     that. General practice was seen very much as something
  10     of a cottage industry. There was no particular training
  11     required. Young doctors who had finished medical
  12     school, and indeed at one point not even doing the
  13     pre-registration but going straight into practice.
  14     Personally I qualified in 1974 and there were some
  15     people in my year who did a pre-registration year and
  16     went straight into general practice without further
  17     training. Legally they were able to do that. You
  18     cannot do that now.
  19        I think part of the different status, and I think
  20     it would be wrong to say there was not a different
  21     status, was due to that perceived lack of training
  22     needed and therefore again seeming to reinforce that
  23     there is no particular skill and no particular skills
  24     needed in being a general practitioner, other than the
  25     basic medical qualification.

   1        I think what we have seen subsequently, and again
   2     it is highlighted in some of our evidence that the
   3     College did not accept that view; the College recognised
   4     early on that there was a set of learning, a body of
   5     learning and experience that those entering general
   6     practice needed to acquire. Perhaps the key time for
   7     the College, the key opportunity for the College, was
   8     the Royal Commission on Medical Education. The College
   9     made, as far as I can understand it, a strong and cogent
  10     case for recognised vocational training for general
  11     practice, and that was largely accepted by the Royal
  12     Commission. Its implementation was perhaps inevitably
  13     modified somewhat by government but resulted in
  14     vocational training regulations. There had been various
  15     contractual changes as well.
  16        I think that the standing of general practice and
  17     general practitioners' roles at that time, and indeed
  18     some people talk of a particularly golden age of general
  19     practice in the 1970s and into the 1980s, when I think
  20     that general practice in a sense really became
  21     recognised as a discipline medically in its own right,
  22     with its own body of knowledge. So I think it has
  23     improved since then.
  24   Q. And the continuing work of the College in such things as
  25     the Fellowship of assessments which we will come back

   1     to, can be seen in part as part and parcel of that
   2     developing professionalisation of the GP's role; is that
   3     right?
   4   A. Yes, I think it is. I think that has also been
   5     acknowledged by some of the other medical Royal
   6     Colleges: the work that general practice has done, for
   7     example, in looking at the quality of the consultation,
   8     the bread and butter of the general practitioner, will
   9     obviously spill over into the work of consultancy, and
  10     so on, and also the way in which, when vocational
  11     training came into being, the way in which the College
  12     helped to set standards and so on, and do proper
  13     assessments of training, which some of the other
  14     colleges perhaps had not been so familiar with, and have
  15     subsequently developed.
  16        But I think again, there was that recognition by
  17     other professional organisations of the work of the
  18     College.
  19   Q. What about the changes in the contracting power of GPs?
  20     Throughout this period we have seen the development of
  21     GP fund-holding as a result of the NHS changes in 1989.
  22     Do you think they have had any impact on the status of
  23     GPs or the perception of GPs amongst the medical
  24     profession?
  25   A. I am sure that that, along with a number of other

   1     things, will all have contributed to that. I think that
   2     fund-holding produced some tensions as well as perhaps
   3     opportunities, and of course it created tensions amongst
   4     general practitioners as well as between general
   5     practitioners and hospital specialists. I think that
   6     a number of general practitioners, many in the College,
   7     found it an inappropriate way to move forward, but
   8     others embraced it very much. Those who embraced it
   9     seemed to be of the view that it gave them a degree of
  10     more influence, both where patients were seen, and that
  11     again comes back to the advocacy issue we touched on
  12     earlier, but also in terms of trying to ensure some
  13     quality standards that they wished to see incorporated
  14     into contracts with hospitals, in a way that they just
  15     have not been able to before.
  16        Of course, we are now moving on to a stage where,
  17     in England, with primary care groups, all general
  18     practitioners will be involved in what has been called
  19     commissioning of care, and I think that actually has
  20     eased tensions between general practitioners, because
  21     now everybody is involved in that process, or at least,
  22     everybody in England, because it is different in
  23     Scotland, Wales and Northern Ireland.
  24   Q. If we return, then, to the 1983 article, that was
  25     perhaps part and parcel but also an important stage in

   1     the quality initiative that was being developed by the
   2     College at the time, and perhaps the next milestone was
   3     the 1985 publication, the policy statement on quality in
   4     general practice, which I think is to be found at
   5     page 666 of the documents you have provided.
   6        That is the title page, but would it be right to
   7     see that as a statement which in many ways opened up the
   8     debate on the career development of the general
   9     practitioner?
  10   A. Yes, I think that would be a fair summary.
  11   Q. If we look at page 671, we have there the preface to the
  12     document. We see there, at the paragraph beginning
  13     "This is the background ..." that the College said that
  14     "The document reflected our understanding of the forces
  15     for change and underlines our belief that good general
  16     practice is still the best way of providing primary
  17     health care."
  18        It went on to say that the document "outlined
  19     a strategy which will lead to substantial improvements
  20     in patient care by creating the climate and establishing
  21     the conditions in which all members of the practice team
  22     have the time and opportunity to realise their full
  23     potential for the care of their patients."
  24        Then the "strong preference for self-regulation"
  25     is then set out.

   1        At the top of the next paragraph:
   2        "The urgent need now is to implement this policy
   3     in every general practice."
   4        Would you like to summarise the aims or hopes
   5     behind this quality initiative?
   6   A. The hope and underlying aim was of course to improve
   7     care for patients across the board. There was a variety
   8     of ways in which this was to be effected, and I think in
   9     many ways was effected. General practitioners were
  10     being encouraged much more to work with colleagues,
  11     nurses, health visitors and so on, administrative staff,
  12     to begin to scrutinise the quality of their work in
  13     a way they had not done before: new mechanisms through
  14     medical audit, clinical audit and so on were being
  15     developed; different educational methods where we might
  16     be sharing from different professionals and so on,
  17     rather than just taking part in unit professional
  18     activity, were being encouraged. I think that general
  19     practitioners were being encouraged to be rather more
  20     open, shall we say, about shortcomings, on the basis
  21     that if you are looking at, for example, the care of
  22     patients with diabetes, it was better in terms of
  23     improving care to identify how well you were doing,
  24     warts and all, but to measure that, identify ways in
  25     which we might improve on that care, and then reassess

   1     at a future date how you had done, having implemented
   2     what you hoped were the changes to improve that care.
   3   Q. If we turn on to page 672, in the introduction to the
   4     document we see in a little more detail what it is
   5     about. If we drop down to paragraph 3, you see there
   6     really the same analysis as was set out in the article
   7     we have already seen: a problem of a degree of
   8     inconsistency, and then the need that the Council had
   9     identified -- I am looking at the very bottom of the
  10     page -- that patients should have an assured standard of
  11     care as a result.
  12        At the top of paragraph 5 in the next column,
  13     general practice was showing its ability and willingness
  14     to change and in particular, the document notes, "the
  15     attitude of general practitioners to quality assessment
  16     are changing."
  17        Can you help us as to what had been problems in
  18     the development or the attitude of general practitioners
  19     to quality assessment?
  20   A. I think that there had been sometimes a reluctance to,
  21     I suppose, initially investigate oneself, but then to
  22     share with colleagues how one was doing on the basis
  23     that many people found it difficult to acknowledge or
  24     admit they may have some failings in the quality of
  25     their work. I think that the culture was shifting at

   1     the time of this document and subsequent. To actually
   2     encourage that change, or to encourage change, such that
   3     it was to be valued to be more open and so on, in that
   4     that was a way forward, I suppose that fitted in with
   5     views about quality improvement in other spheres, in
   6     business, commerce and so on, and this was its
   7     application into general practice. I think at times
   8     people are reluctant to take on board new ideas, so
   9     I suspect there may have been a reluctance there.
  10     I think some would argue that the things like the
  11     infrastructure support for general practice also varied
  12     up and down the country. The independent contractor
  13     status has some strengths; it inevitably has weaknesses
  14     as well. There is no doubt in some parts of the
  15     country, perhaps more deprived areas, even the physical
  16     surroundings, the general practitioner's surgery, the
  17     opportunity to have nursing and health visiting staff
  18     based in the surgery, the amount of funding that was
  19     available from the Health Authority for developments in
  20     general practice, many of these things would have been
  21     variable and in some areas I suspect not very good.
  22        So there are a number of issues that would have
  23     prohibited it. I suppose that many would also have seen
  24     time as being an issue as well; the lack of opportunity,
  25     whether perceived or real, I suspect it may be a mix of

   1     both, the lack of time to spend doing these activities.
   2   Q. If we just return to the first issue you were looking at
   3     there, the question of culture and the difficulty that
   4     many would have in admitting mistakes, discussing
   5     mistakes with colleagues, but also the shift in that
   6     culture that you were identifying, the movement from it,
   7     is that pattern something which is unique to GPs, or is
   8     it a comment that would have more general validity
   9     across the way medicine has developed and doctors have
  10     been, as it were, socialised?
  11   A. I think it is a change of culture within the medical
  12     profession. It is certainly not unique to general
  13     practice. There are differences perhaps in the way it
  14     would be implemented, but -- I think it was part of
  15     a movement, if you like, a shift more generally.
  16   Q. How far do you think that movement has progressed since
  17     this document was written?
  18   A. I think it has progressed some way, and I think there
  19     are arguments in some areas to say it has progressed
  20     a very considerable way. But there will be other areas
  21     where it has not progressed as much as we would like.
  22     By that I am thinking particularly perhaps of the
  23     clinical area. To give a specific example, one of the
  24     contractual changes in the early 1990s allowed
  25     additional payments for general practitioners providing

   1     specific care for those patients with asthma and those
   2     patients with diabetes, so that was, if you like, a bit
   3     of a carrot to encourage general practitioners and their
   4     teams to look particularly at the care they were
   5     providing for those groups. I suspect that many general
   6     practitioners did look at the care of those groups, and
   7     that that had an impact on that.
   8   Q. In fact, the question of financial incentives and the
   9     importance that they may have on encouraging certain
  10     types of practice is picked up further in the document
  11     at page 677. I should say, for the sake of the record,
  12     that the quality initiative is set out on the pages that
  13     follow, but obviously one is reluctant to go through
  14     every paragraph, but it will be available on the
  15     transcript for those who wish to read it.
  16        If we look at paragraph (c), if we can scroll down
  17     the page a little, this is the question here being
  18     discussed of continuing professional education, medical
  19     education, and it points out under (c) the assessment of
  20     established principle:
  21        "In this country [at the time the document was
  22     written] the only financial incentive for good general
  23     practice was in the selection and reselection of
  24     trainers" and it then sets out the contract system.
  25        At paragraph 34 we have the proposals from the

   1     College which state in particular that the College has
   2     decided to give more formal recognition to sustain
   3     performance in continuing professional development as an
   4     essential factor in making the award of Fellowship.
   5        That really is the core of what then developed
   6     into the Fellowship by assessment, is it not?
   7   A. Yes.
   8   Q. If we go up to the next column, we see that in
   9     developing these new practices, there is a recognition
  10     there -- I am looking about seven lines down -- that
  11     there would need to be a financial incentive.
  12        Can I just ask, firstly, what financial incentive
  13     has it proved possible to develop to encourage the
  14     Fellowship by assessment specifically?
  15   A. Again, it is variable. The majority of people who
  16     undertake Fellowship by assessment are doing it for
  17     their own professional development, and that is still
  18     the overwhelming motive.
  19        There are some health authorities up and down the
  20     country -- there are a handful, I think about 6 to 8 --
  21     who have seen the criteria for Fellowship by assessment
  22     and indeed, one for practice now, which is called the
  23     Quality Practice Award -- who acknowledge that this is
  24     an explicit exercise in setting and achieving high
  25     standards of care, and are prepared to put some

   1     recompense into the individual and into the practice to
   2     do that.
   3        It has varied from about œ1,000 to œ2,000,
   4     roughly, depending on the Health Authority, but the
   5     majority of people who undertake Fellowship by
   6     assessment have no financial incentive, so to speak,
   7     either at the time to help them with their time and
   8     effort at the time of doing it, or indeed subsequently.
   9   Q. That is a mixed blessing: one may applaud the interest
  10     in education that those who nevertheless undertake it
  11     and succeed show; on the other hand it may well be that
  12     one of the obstacles to developing a culture of
  13     continuing medical education is the question of the
  14     absence or presence of real financial or other
  15     incentives to engage in this form of conduct.
  16        What is the College's attitude on the ways in
  17     which such continuing professional education can best be
  18     fostered?
  19   A. I think, just as a comment about the payment for
  20     quality, the doctors and dentists review body just last
  21     year recognised the whole issue of quality and suggested
  22     that there be some available for that, for general
  23     practitioners, and some of that has been worked out,
  24     some detail is still being worked out, so there has been
  25     recognition at that level.

   1        I think in terms of continuing medical education
   2     or continuing professional development, and sometimes
   3     the two are used interchangeably, the College certainly
   4     is of the view that it is important for doctors, and
   5     indeed other health professionals, to undertake regular
   6     continuing professional development, and indeed, it is
   7     one of the points, one of the criteria that prospective
   8     members and continuing members sign up to. In becoming
   9     a member you actually agree to uphold the College's
  10     principles and you will undertake to keep up to date, so
  11     that is there in a general sense, but it is not
  12     reaffirmed in any sort of --
  13   Q. Form of sanctions?
  14   A. Any formal way; it is more a given undertaking.
  15     Certainly the College is of the view that it should do
  16     it and the College has been very supportive of the GMC's
  17     stance on revalidation, and over the past year or so,
  18     the profession has been having discussion about
  19     re-accreditation or re-certification or what is now
  20     revalidation. The College has been developing its own
  21     views on how and what form that might take, and we are
  22     developing a system that is to be called "Accredited
  23     Professional Development" which will be voluntary
  24     initially and will certainly expect that the doctor will
  25     take into account in his or her learning needs, in his

   1     or her professional development needs, areas of clinical
   2     care, and areas that need to be improved upon.
   3        There is some evidence that doctors, in
   4     undertaking their continuing education, and I suspect it
   5     is true of other groups, not just doctors, tend to go to
   6     courses about things they know quite a lot about anyway,
   7     and that, I think, as I say, is a more general truth.
   8     So what APD will do is encourage general practitioners
   9     to look perhaps at areas that they may be relatively --
  10     "neglected" is perhaps too strong a word, but where
  11     they may not be too strong on and encourage them on
  12     that, and put it into the context of what the practice
  13     needs. It would not make a huge amount of sense for six
  14     partners in a practice to go off and hone their skills
  15     on minor surgery if that is not what the patients need.
  16     So we will be doing that.
  17        There will be some portfolio that the practitioner
  18     will develop which will be proof of their professional
  19     development. With 33,000 general practitioners in the
  20     country and 18,000 college members, it will be difficult
  21     to do that, to examine everyone, but the idea is that
  22     there will be a sampling, if you like, of portfolios
  23     nationally and locally.
  24   Q. I think that the question I was seeking to explore with
  25     you is, what will be either the incentives or the

   1     sanctions, the positive and the negative, for
   2     participation, successful participation, in such
   3     a scheme?
   4   A. One of the issues that the College has been looking at
   5     for the past year or two has been the meaning of its
   6     designations MRCGP and FRCGP. At the moment, really, it
   7     has been taken as being proof of having passed the
   8     examination, and there has been no formal requirement to
   9     keep up to date, so, for example, if you do not
  10     undertake a particular course of CPD, it does not mean
  11     that you will lose your membership or Fellowship. We
  12     have been looking at that and obviously there is a view
  13     that it would be possible to de-register someone, if you
  14     like, who did not undertake that, and that is still the
  15     subject of discussion within the College. It is
  16     obviously a two-edged sword, as it were, for the
  17     College, in that we would not want to necessarily
  18     exclude people who could be helped by being within the
  19     College.
  20        I think that what we do acknowledge is that
  21     resources are needed to undertake continuing
  22     professional development. Again, there is an issue or
  23     a tension between the general practitioner's independent
  24     contractor status, but also, that the resources that are
  25     available to them, both financial and other, through the

   1     Health Service and I think that there have been
   2     discussions and there will continue to be discussions
   3     about how much is paid for by the individual and how
   4     much is paid for through the service. But I think that
   5     is true of other professions within the Health Service
   6     as well.
   7   Q. We have discussed how this document was at least a key
   8     stage in setting in motion the development of the
   9     Fellowship by assessment and there is a document at
  10     page 305 of the bundle which sets out the Fellowship and
  11     its aims in greater detail. That, I think, is the
  12     second edition, November 1995.
  13        If we look at page 309, there is there, in the
  14     preface of the edition, an introduction to the scheme.
  15     Again, page 311 to 324 give a detailed history of the
  16     scheme. I put those pages, as it were, on to the
  17     transcript for those who wish to read it, but I do not
  18     propose to detain you, Dr Reith, with the detail now.
  19     It is right, I think, that the first elected Fellows
  20     were elected on 18th November 1989, and that since then,
  21     from the 1998 annual report that we have, we glean the
  22     information that some 122 GPs have now attained that
  23     status.
  24        Can you tell us, how do you regard that as being
  25     an indicator or otherwise of the success of the scheme?

   1   A. We would like there to be more. We are now in
   2     a situation where we have roughly 100 Fellows elected
   3     each year, and I use that advisedly because even Fellows
   4     by assessment have to be formally elected at our general
   5     meeting, but 10 per cent of those who achieve
   6     Fellowship, achieve Fellowship now by assessment.
   7        We certainly had hoped by now there would be more
   8     Fellows by assessment and in some of the initial
   9     documentation about Fellowship by assessment absolute
  10     numbers and so on were put on what we hoped to achieve
  11     by such-and-such a year. A number of things happened.
  12     It was always acknowledged that Fellowship by assessment
  13     would be a challenge and indeed, it was set out to be
  14     a challenge to the individual practitioner, but I think
  15     also that November 1989 was round about the time that
  16     a new contract for general practitioners was being
  17     discussed. If you recall, it was one that was largely
  18     imposed rather than negotiated, and I think that that
  19     did little to help the climate of development because
  20     there was quite a lot of tension in the service at that
  21     time. I think that that had an effect. I am not saying
  22     that it had a total effect, but I think that the extra
  23     work and the organisational change that resulted from
  24     the contract, changes in 1990 and organisational
  25     changes, did I think divert many general practitioners'

   1     enthusiasm and energy into more fundamental issues
   2     because there were contractual, and the Fellowship by
   3     assessment suffered somewhat.
   4        It also does take some time to go through the
   5     process, to do all the preparatory work, and we know
   6     that the numbers are holding well in what we call NIAs
   7     [Notification of Intention to Apply] for Fellowship by
   8     assessment, because the criteria changed and somebody
   9     who wishes to sit Fellowship by assessment has to fix,
  10     as it were, the criteria they will be assessed on,
  11     whether it will be the 1999 ones or whether they will
  12     wait until 2000 and be assessed on those.
  13   Q. It was a long process of development, I think, that led
  14     to the introduction of the Fellowship by assessment,
  15     because it involved an extensive first, as it were,
  16     paper, but then field testing of the competencies that
  17     you were defining for general practices to be developed
  18     before you were ready to put it, as it were, into
  19     practice. I think it is also right, is it not, that the
  20     process of testing and further developing, re-evaluating
  21     those competencies continues still?
  22   A. Yes.
  23   Q. It is obviously an assessment process that is very
  24     firmly grounded in the skills required to be shown in
  25     a GP's surgery. That is its purpose?

   1   A. Yes.
   2   Q. But do you think that the approach that you have
   3     developed is something that may have more value across
   4     medicine as a whole and be something that could be of
   5     use to other disciplines as well?
   6   A. Yes, I think it would, and I think part of the reason
   7     for publications such as the one you have the screen
   8     just now on is to publicise this sort of activity. Over
   9     the 1980s, we talked earlier about the quality
  10     initiative. There was another document called "What
  11     Sort of Doctor?" which was perhaps the more discursive
  12     technique where people were discussing what were the
  13     good and no so good attributes. This developed on to
  14     how can we measure these theoretical but nonetheless we
  15     think practical attributes? It is from that, really,
  16     that this developed.
  17        Certainly, it is grounded in the general
  18     practitioner's day-to-day work, and that was always the
  19     intention. The general practitioner has to undertake
  20     a number of audits and studies and so on in his homework
  21     and submit that prior to the assessment. It now also
  22     includes a video assessment of the doctor consulting and
  23     that is examined as well, to see how the doctor does it
  24     on the day.
  25        But it also includes a visit to the doctor in his

   1     or her practice, which is the final part of the visit
   2     and of course, is the actual assessment on the day.
   3        I think one of the things that we have been able
   4     to do, which has worked very well, is that there are
   5     three assessors and one of the assessors is local, and
   6     has worked through the Fellowship by assessment process
   7     with the intending Fellow and that professional support
   8     is very much valued; the other two assessors are from
   9     a completely different part of the country. So again,
  10     it has, I think, enormous credibility within the
  11     practice as being very challenging but an achievable
  12     standard of practice, but also is rooted in day-to-day
  13     practice. I think there would need to be modification
  14     for other specialties, but I would see no reason why
  15     other medical specialties could not develop similar
  16     criteria based equally in the work that they undertake.
  17   Q. Because the Fellowship by assessment for GPs represents
  18     what might be dubbed a "gold standard" for GPs which
  19     singles out or marks excellence in practice?
  20   A. Yes.
  21   Q. And it is something that you were developing across the
  22     1980s?
  23   A. Yes.
  24   Q. Is there any particular reason that you can think of why
  25     the GPs' College may have taken the lead in this

   1     particular form of activity, because I think it is
   2     a unique scheme amongst the other Royal Colleges.
   3   A. We are certainly not aware of anything similar in the
   4     other RCGPs, or indeed, nothing quite like it elsewhere
   5     in the world, although some of the other English
   6     speaking countries are looking at similar things: the
   7     Australian College of General Practitioners and so on,
   8     for example, but I think part of it is the culture
   9     within our College, that it developed from the quality
  10     initiative, the discussions trying to tease out and
  11     develop what was the discipline of general practice, and
  12     I think most importantly, trying to capture what were
  13     the measurable elements of the good quality of practice,
  14     and I think that that is partly down to some of the
  15     individuals that were involved in that time. It was,
  16     I think, a particularly vibrant time intellectually for
  17     general practice, and also may have been, and I suspect
  18     probably was, the College rising in a sense to the
  19     challenge set out in the very first document, Donald
  20     Irving's document.
  21        So, for our College at that time, it seemed the
  22     right thing to do. Other Colleges, I suspect, had
  23     different priorities. But again, I think that even at
  24     that time, even now in Medical Royal College terms, we
  25     are in our infancy, and I think that sometimes in

   1     organisational terms, that relative youth or that
   2     relative youngness does actually allow you opportunities
   3     to look at things and develop things in a way that
   4     perhaps more established organisations tend to draw back
   5     from.
   6   Q. Are there now mechanisms, or were there then mechanisms
   7     for collaboration between the Royal Colleges on the
   8     development of initiatives such as this?
   9   A. There is now something called the Academy of Medical
  10     Royal Colleges which may have been mentioned already
  11     during the Inquiry, and that is an opportunity, there
  12     are regular meetings between all the Presidents of all
  13     the Royal Colleges to meet regularly. That used to be
  14     called the Conference of Medical Royal Colleges, but my
  15     understanding at that time is that when it was the
  16     Conference of Medical Royal Colleges, it was more --
  17     I think it developed as some of the Presidents of the
  18     Royal Colleges getting together to keep in touch
  19     basically, I think, and then obviously they became more
  20     formalised and included all the Royal Colleges,
  21     including our own, and I think has become more
  22     formalised. I think there has in more recent years been
  23     more sharing of ideas and developments. I think all the
  24     Colleges have begun to develop the thinking of quality
  25     issues.

   1   Q. One of the limitations which must be inherent in
   2     a scheme such as the Fellowship by assessment is that
   3     there must be a danger that to some extent one is,
   4     I would not say preaching to the converted, but
   5     nevertheless you have a scheme which is addressing some
   6     of the leaders in patient care in the first place, so it
   7     is not a scheme that is perhaps developed in order to
   8     target problems of poor performance. Is that fair?
   9   A. Yes, that is fair. It is certainly looking at the range
  10     of excellence rather than the range of
  11     under-performance.
  12   Q. So what are the College's initiatives that are designed
  13     to address the poor performing doctor? Is that the
  14     question of the continuing medical education, the APD
  15     scheme that you have already addressed?
  16   A. That will be part of it, but I think that just very
  17     briefly, if I may tell you something of the other
  18     initiatives that are going on to look at performance,
  19     the College's examination was founded in the late 1960s
  20     and has been continuously modified and adapted over that
  21     time. However, for many years it has been acknowledged
  22     that it is an examination or an assessment that is most
  23     appropriately taken towards the end of vocational
  24     training, so it is undertaken by the doctor about to
  25     enter general practice, independent practice.

   1        We are aware that for various reasons people
   2     perhaps who trained a few years ago were not necessarily
   3     encouraged to take the College's examination. They did
   4     not see the relevance of taking it at the time. They
   5     have in a sense been excluded from College activities
   6     and we know that many of them would like to have
   7     belonged to the College. There is really at the moment
   8     no alternative but to do the exam, which is not intended
   9     for the practitioner who has been, say, then years in
  10     practice.
  11        Over the past couple of years or so, we are
  12     developing something called "Membership by assessment of
  13     performance" and that has now become effective and went
  14     through our annual general meeting in November last year
  15     and actually has gone live as of 1st April.
  16        Basically, what that is, again it started off in
  17     a similar way to Fellowship by assessment, that a group
  18     of doctors sat down, decided what was acceptable or not
  19     acceptable performance for the practising practitioner
  20     in providing a good standard but not necessarily the
  21     excellent standard of the Fellowship by assessment. We
  22     have developed criteria very similarly to Fellowship by
  23     assessment, and indeed, there has been a tremendous
  24     interest in this from many established practitioners who
  25     are not members, and we are now receiving applications

   1     for that. Of course, what we are trying to do is to
   2     gain consistency of methodology so that, for example,
   3     Membership by assessments of performance includes the
   4     candidate requiring to produce a video of consultations
   5     just as Fellowship by assessment does. Some of the
   6     other things are very similar as well, but obviously,
   7     when we are looking at Fellowship by assessment,
   8     a higher standard is expected. We hope that large
   9     numbers of general practitioners will be encouraged to
  10     do Membership by assessment of performance.
  11        We also have similar initiatives for practices,
  12     because again the independent practitioner, his or her
  13     work is intricately bound up with that of the practice
  14     as a whole. We already have a Quality of Practice award
  15     which is akin to Fellowship by assessment but for the
  16     practice rather than the individual, and have piloted
  17     something called "practice accreditation" and in fact
  18     have just received fairly substantial funding to develop
  19     that into what will be called "quality team
  20     development".
  21        So there are other initiatives like that.
  22        I think it is fair to say that none of those are
  23     primarily geared to picking up the underperforming
  24     doctor, and I suppose that where we are coming from is
  25     the premise that doctors wish to provide good quality

   1     care for their patients where they are to encourage and
   2     support, and achieve that, and actually also to be able
   3     to demonstrate it and I think that what we can provide
   4     as an organisation is partly the support but actually
   5     also the context, because I think that for the
   6     individual practitioner, it is often difficult to know
   7     how they are doing without any sort of comparison by or
   8     with their colleagues.
   9   Q. So your strength is in setting and developing standards
  10     of good practice, and then being an educational tool to
  11     enable members to reach those standards, rather than
  12     a body which is applying sanctions or disciplinary
  13     forces against its members?
  14   A. Yes.
  15   Q. How would you assess the ability of the College to
  16     influence the conduct of GPs when one sets its influence
  17     against all the range of factors that must impact upon
  18     a GP's performance? What is the impact of the College?
  19   A. I think the impact of the College in developing
  20     a general practice and general practitioners over the
  21     past 40/50 years has been very significant. I think
  22     that the College is seen by both members and non-members
  23     as an organisation which takes care to tease out what
  24     the issues and problems are, will undertake some
  25     research and evaluation, try to measure things in

   1     objective ways, and set standards which at times may
   2     seem a little daunting to some people, but actually are
   3     based in reality, nonetheless, but yet are encouraging
   4     people to do better.
   5   Q. You have spoken in your statement of the work that the
   6     College also does in the accreditation of hospital
   7     teaching posts for the purpose of GP training, and
   8     I think the Inquiry would ask that any records that are
   9     available to you or in the power of the College of any
  10     visits to the BRI be made available to it, but that is
  11     not something we can address here and now, today.
  12        In general, were you, as a college, ever in
  13     a position or required to use the powers at your
  14     disposal to sanction hospitals if the training made
  15     available in them did not appear to be suitable or
  16     sufficiently good for GPs?
  17   A. Yes, if I can just take your first point first, and just
  18     confirm that we will be very happy to look and see what
  19     records may be available, either locally in the Bristol
  20     area or indeed through the Joint Committee on
  21     postgraduate training, about Bristol Royal Infirmary
  22     particularly.
  23        The regulation of hospital posts as far as general
  24     practice is concerned is now done through the Joint
  25     Committee for Post-graduate Training for General

   1     Practice, of which the College is a parent body. The
   2     other parent body is the General Practitioners'
   3     Committee of the BMA, previously the General Medical
   4     Services Committee.
   5        The responsibilities of the Joint Committee have
   6     changed recently as a result of legislation and that
   7     legislation is primarily brought in to bring the UK into
   8     line with European legislation. I can certainly outline
   9     roughly what that assessment is, if you wish.
  10        To answer your last question about has any
  11     hospital ever been de-approved, if you like, for
  12     training, there was a particularly memorable event a few
  13     years ago, when in fact the whole region was debarred
  14     from -- well, the Joint Committee's decision was to
  15     debar the region from training, but it did not take
  16     effect immediately. Obviously there would have been
  17     very considerable problems for doctors then in training,
  18     so that the region was notified that its training status
  19     would be removed at a future date.
  20        In fact, what happened in the interim was that
  21     significant changes were made in the nature of training
  22     and that did not need to take place.
  23        I do know that since the past year or 18 months,
  24     since the Joint Committee's responsibilities have
  25     changed, particular posts in certain hospitals in the UK

   1     have been withdrawn from training as a result of the
   2     visiting process.
   3   Q. What is the effect of that sanction? What importance
   4     does it have to the hospital concerned?
   5   A. It certainly causes people to focus their attention on
   6     the issues and efficiencies. Again, one of our concerns
   7     is to not adversely affect patient care, obviously, but
   8     also not to compromise unnecessarily the doctors that
   9     may be in post in training, because they obviously may
  10     find themselves in a difficulty as well.
  11        Basically, what will happen is that the visit to
  12     a hospital will include discussion with hospital
  13     consultants about the training that they offer to young
  14     doctors; it will include discussion with the young
  15     doctors in training about their experience, and will
  16     also include discussion with the GP course organisers
  17     for that particular scheme. If there is corroborating
  18     evidence -- one of the difficulties may be that it may
  19     be that for example, a young doctor in training has
  20     particular criticisms of a particular post. Other
  21     information may suggest that that is not the case, or
  22     accepted widely, so obviously a judgment has to be made,
  23     but if the balance of evidence seems to be that the post
  24     is unsatisfactory, at the end of the three-day visit,
  25     the visitors will notify the organisers that they are

   1     very concerned about this, and their recommendation will
   2     be that the post not be approved.
   3   Q. Why would that be of concern to the hospital in
   4     question?
   5   A. What happens then is that if the training status is
   6     removed, the hospital is not then allowed to employ
   7     young doctors or to advertise the post as a training
   8     post. They can cover the post by making it a service
   9     post, but the level of posts that are used for general
  10     practice training tend to be some of the more junior
  11     ones, the Senior House Officer posts, the overwhelming
  12     majority of them in the UK are training posts, so the
  13     hospital would probably find it difficult to attract
  14     staff to undertake those posts.
  15   Q. Thank you. If I could come back to page 10 of your
  16     statement, this is the part of your statement in which
  17     you first start to address the subject of referrals from
  18     GPs to specialised practitioners of children who might
  19     be suffering from cardiac congenital heart problems.
  20        Throughout your statement in dealing with this
  21     issue, you make the general point that a GP would rarely
  22     encounter a child with a congenital heart defect in his
  23     or her practice. I am looking there at paragraph 2.1.2,
  24     at the bottom of that page, where you point out that the
  25     conditions are rare and that the average list size would

   1     only contain 10 patients of all ages affected by
   2     congenital heart disease, with one new case arising
   3     about every five years.
   4        The reference that you have given there, again for
   5     the sake of the record, is to an article which appears
   6     at page 774 of our bundle.
   7        You go on to say that the initial diagnosis of
   8     a heart defect would be likely to take place on the part
   9     of a paediatrician, or possibly a paediatric
  10     cardiologist, depending on the nature of the defect, at
  11     the hospital to which the child had been referred and
  12     that therefore, by the time a GP had contact with
  13     a child with such a defect, it might well be that both
  14     diagnosis and a course of treatment, even surgery, had
  15     taken place.
  16        If we could take the case of a child whose heart
  17     murmur, say, had not been picked up at birth and whose
  18     mother, the child had been discharged from the Maternity
  19     Hospital, but then the child fails to thrive and is
  20     brought in to the GP because she is not feeding
  21     properly, something like that, and the GP therefore is
  22     contemplating referral to a paediatrician, I think that
  23     is the scenario you have painted as being a realistic
  24     one?
  25   A. Yes.

   1   Q. Can I ask, if the GP is considering whether to refer to
   2     a paediatrician, on what data or information would the
   3     judgment as to the adequacy or the service likely to be
   4     provided by that paediatrician have been based?
   5        If we could look first, perhaps, at the period
   6     from 1984 to 1989, before the development of the NHS
   7     changes and reforms, what sort of data would have been
   8     available to a GP at that time?
   9   A. Not very much, in all honesty. I mean, much of the
  10     general practitioner's decision to refer will be on the
  11     basis of personal knowledge. Over time, a general
  12     practitioner will get to form a view, an opinion, on the
  13     range of abilities and indeed the range of
  14     specialisation of consultant colleagues, and again,
  15     different specialties have evolved at different rates,
  16     so, for example, in surgery, there was some
  17     specialisation some time ago, a number of years ago, in
  18     many centres into surgeons specialising in breast
  19     surgery, thyroid surgery and that sort of thing. In the
  20     surgical condition of ophthalmology, it is only now there
  21     is specialisation into those dealing with retinal
  22     problems, and so on, so again it must be taken in that
  23     context.
  24        Whether or not one would refer in the particular
  25     instance to a paediatrician or a paediatric cardiologist

   1     would depend to an extent on local practice. Probably,
   2     a large chunk of the population and their GPs do not
   3     have immediate access to a major hospital and many of
   4     them will be seen through district general hospitals
   5     which will tend to have a general paediatrician rather
   6     than a paediatric cardiologist. That again, I am sure
   7     you will appreciate, is due to population size and so
   8     on. So there are many parts of the country where
   9     a general practitioner will refer on to a general
  10     paediatrician. There may be five or six paediatricians
  11     in the hospital and perhaps one or two of them might
  12     have a special interest in paediatric cardiology. That
  13     would not be the whole nature of their work, but
  14     obviously they have a particular interest in that.
  15   Q. If I could just stop you there for a moment, you mention
  16     in your witness statement an article and a letter in
  17     reply which effectively make the point that there is
  18     still some debate as to the merits of a referral direct
  19     to a paediatric cardiologist as opposed to
  20     a paediatrician in the first instance.
  21   A. Yes.
  22   Q. Is that something on which there is a consensus of
  23     medical opinion now, or is this a matter which varies
  24     from area to area?
  25   A. I think, again, that still varies. I think the issue is

   1     more one of ready availability to the general
   2     practitioner and indeed the patient, so that, for
   3     example, if you had a general practitioner practising
   4     perhaps in the far south west down in Cornwall,
   5     somewhere, he or she would be much more likely, I would
   6     have thought, to send the child to the local district
   7     general hospital, even if he thought it was a cardiac
   8     problem, rather than sending up to Bristol or into
   9     London, simply in terms of the initial process, getting,
  10     if you like, a more specialised opinion initially, and
  11     then getting the view of that colleague as to whether or
  12     not further referral or investigation was needed,
  13     because I think again the article does say that in
  14     a very significant number of children, further
  15     investigation is not actually necessary.
  16        So again, it is a judgment about the patient
  17     getting the care that the patient needs with convenience
  18     in terms of the difficulties that some patients have in
  19     travelling long distances or going to the nearer
  20     hospital. I think the issue about the availability of
  21     paediatric cardiologists is, I suspect, one more about
  22     population size and again, the whole issue of keeping up
  23     with the expertise. It would not seem to make sense to
  24     have a very specialised doctor, for example,
  25     a paediatric cardiologist, in every district general

   1     hospital. They would just not be seeing the volume of
   2     work that would keep up their skill and so on.
   3   Q. So if we return to the question of our representative GP
   4     back in 1984 to 1989, and he or she is deciding whether
   5     to refer a child he suspects may have a heart murmur,
   6     may be innocent, may not be, on what sort of factors is
   7     he or she going to base his or her decision as to
   8     whether or not to refer a child to a particular
   9     paediatrician or a particular hospital?
  10   A. It will, as I say, I would have thought, be that for the
  11     majority, the initial thought would be to refer to the
  12     local district general hospital. Obviously those in
  13     a city like Bristol would have the opportunity of
  14     referring directly to a paediatric cardiologist, but it
  15     is the availability of the hospital. The particular
  16     interest and area of expertise of the paediatricians,
  17     and again, if the general paediatrician had a special
  18     interest in cardiology, it would seem that that would be
  19     the individual that would seem most appropriate to refer
  20     to. I think again, from what I have said about
  21     population size, there may not be a huge choice in that;
  22     there may just be one or perhaps two with that
  23     particular interest.
  24   Q. What sort of information or messages, to put it more
  25     generally, would have been available to the GP about the

   1     competence or the service that might be being provided
   2     by those paediatricians?
   3   A. I do not think there would be any regular information
   4     coming from the hospital about the case mix or anything
   5     like that, or the range of patients and so on that the
   6     particular consultants were seeing. There is the
   7     overall and to some extent very general reassurance
   8     general practitioners would get from the appointment
   9     process for a consultant, whereby a consultant vacancy
  10     came up or occurred, a number of applicants presumably
  11     would be interviewed and the interview process for
  12     consultants, as I am sure you are aware, does include
  13     a Royal College representative, the Royal College of
  14     Paediatrics or Child Health, I suppose, would be on the
  15     appointment panel and that would be a general assurance
  16     that a person who had been suitably trained, who had
  17     completed their certificate in specialist training, had
  18     been appointed.
  19   Q. So there is the general faith, as it were, that the
  20     system will function and generally does function
  21     adequately in most cases?
  22   A. Yes.
  23   Q. What about sort of word-of-mouth? Do messages filter
  24     out from patients as to the experience they have had
  25     with particular consultants they have seen?

   1   A. Yes. There will be what one might call local
   2     knowledge. General practitioners individually will form
   3     opinions about how well consultants have dealt with
   4     patients in the past. They will come across consultants
   5     at meetings, there will be a feedback from patients
   6     about how consultants appear to have been in their
   7     manner and how well they have related; there will be
   8     issues about how easy the consultant is to contact, to
   9     discuss things over the phone; how quickly
  10     correspondence comes through. It is, I suppose, like
  11     a jigsaw, really, and all of these will come into
  12     account.
  13        There will also, of course, be discussions with
  14     colleagues, with partners in one's own practice, on
  15     one's experiences.
  16   Q. If that was the position from 1984 onwards, did anything
  17     of any significance change after 1989, or more
  18     accurately, around 1991 and thereafter, when the NHS
  19     reforms were put into practice?
  20   A. Presumably you mean particularly fund-holding?
  21   Q. Yes, I am talking specifically of a fund-holder GP who
  22     might therefore have perhaps more choice or have to
  23     consider more widely who he or she referred to.
  24   A. I suspect in a field as specialised as this, probably
  25     not a huge difference, frankly. Some hospitals did

   1     begin to produce some information about the services
   2     that were available, and these would be sent out to
   3     practices, but this was variable up and down the
   4     country. Again, remember that not all GPs took part in
   5     fund-holding, but those who did had a degree of
   6     flexibility in referring for outpatient assessments and
   7     so on. But again, they would take into account their
   8     view of the local hospital, the facilities there, and
   9     expertise of the staff there, and again the patient's
  10     view in terms of distance travelled and so on. In
  11     paediatric cardiology and so on, I would doubt it would
  12     make much difference, frankly.
  13   Q. If we are talking about a fairly specialised service,
  14     remembering always I am taking the example of referring
  15     to a paediatrician rather than to a paediatric
  16     cardiologist, because that would appear to have been the
  17     norm, would it have been the case that GPs were getting
  18     or picking up more information about less specialised
  19     situations? I mean, for instance, referrals for hip
  20     operations, to take one example, as opposed to referrals
  21     to children with conditions they might encounter fairly
  22     rarely.
  23   A. I think, I mean, in some parts of the country where
  24     there were a number of hospitals to choose from,
  25     providing similar services and seeming to be of

   1     a similar quality, yes, general practitioners may have
   2     changed their referral pattern a bit, but I do not
   3     think -- I suspect this is one of the reasons why
   4     fund-holding did not seem to take off in the way that
   5     some had initially assumed it would, because in fact
   6     there was not a huge impact on that. Contracts for GPs
   7     for services with hospitals did not shift around
   8     hugely. I think again that is partly because of the
   9     general practitioner's knowledge of a local hospital,
  10     and also patients affinity, really. I think in many
  11     parts of the country patients -- it is very
  12     reassuring -- have particular views of the abilities of
  13     a hospital and we only have to see the public outcry if
  14     a hospital is threatened with closure. People are very
  15     warm to their own hospital.
  16   Q. Were GPs at any time agitating or pressing for further
  17     information about outcomes, about clinical performance,
  18     or was, on the whole, GP pressure directed to such
  19     things that have had a great deal of attention in the
  20     NHS, such as waiting lists for their patients or
  21     possibly cost of procedures?
  22   A. I think it has been more looking at the length of time
  23     that patients perhaps have had to wait; the length of
  24     time that it takes to get referral letters back from
  25     hospital, from the consultant, changes in treatment and

   1     so on, so I think it has been more on that side and
   2     particularly in the time you are mentioning, in the
   3     early 1990s, and so on, there was not such interest in
   4     outcome indicators, and so on, that there is currently.
   5   Q. If we go to your statement at page 14, you mention at
   6     the top of that page, perhaps 2.2.4, that with respect
   7     to Bristol, general practitioners were referring to
   8     a hospital that was known to be approved as a major
   9     teaching hospital in the UK and was funded as such by
  10     the Department of Health.
  11        Are those the sorts of triggers that would have
  12     been important in establishing that a hospital such as
  13     Bristol would be likely to be regarded as providing
  14     a decent standard of care?
  15   A. Yes. I think it would. I do not think it would
  16     necessarily be uppermost in the mind of general
  17     practitioners, "We will refer to Bristol Royal Infirmary
  18     because it is a major teaching hospital" or "it is
  19     funded by the Department of Health", but that knowledge
  20     is there. Given the various checks in the system,
  21     I think it is not unreasonable for a GP to supervise
  22     that there are high standards of care taking place.
  23   Q. That assumes that one assumes the best and the system is
  24     working adequately, unless a particular scare story or
  25     some particular incident occurs that triggers alarm

   1     bells?
   2   A. Yes. It does.
   3   Q. If we take the next paragraph:
   4        "We are unable to identify information which was
   5     supplied to a general practitioner which would lead them
   6     to doubt the performance of any particular unit in that
   7     hospital."
   8        That simply is eliminating the possibility that
   9     you may have information on Bristol that would have been
  10     of relevance to the Inquiry, is it?
  11   A. No, in preparing evidence, I did contact -- as
  12     a national College we have a faculty structure which is
  13     sort of the local area, so, for example, Devon and
  14     Cornwall are one area and Severn is another, and so on,
  15     so that it seemed to me that it would be helpful to ask
  16     of our faculties if any information had been available
  17     to them. The reply we got back from them was that there
  18     had not been any information. I think, in fairness to
  19     the hospital, I suspect I would have got the same answer
  20     had it been another hospital in another part of the
  21     country that I asked.
  22   Q. The word "that" in "that hospital" implied there might
  23     be other hospitals in which the answer might be
  24     different?
  25   A. No such implication was intended.

   1   Q. If we go on to paragraph 2.2.6 of your statement, you
   2     say that if information were available to the GP, more
   3     detailed information about outcomes and so on, it would
   4     be difficult for an individual GP to interpret because
   5     of each unit's case mix and that the GP would normally
   6     rely on the consultant paediatrician for their
   7     interpretation of the case mix and the severity of each
   8     case within it.
   9        There are possibly two different issues that are
  10     underlying that paragraph, and I would like to ask your
  11     comments on both.
  12        The first is the question of the interpretation of
  13     what might be specialised data. I think what you are
  14     saying, perhaps, is that crude figures such as mortality
  15     rates would not, of themselves, be of any particular
  16     assistance to GPs unless there was some information that
  17     put them in context?
  18   A. Yes. That is part of it, but I think there is also the
  19     issue about whether the GP is the best person to
  20     interpret the data anyway, and I think that is the point
  21     about the consultant paediatrician there.
  22   Q. So there is an absence of specialist knowledge that
  23     would enable a GP to make the best of information; it
  24     needs to be done by a specialist?
  25   A. For certain specialties, that would be the case, and

   1     this is one. Again, it is to do with the rarity of the
   2     condition or conditions, and relates back, I think, to
   3     the earlier comment that the average GP will see one
   4     case of complex cardiac problems in children every five
   5     years and that it is very difficult to then relate back,
   6     if you have patients who are affected, to remember back
   7     to what happened so long ago in that particular field.
   8   Q. But what information, accompanied by specialised
   9     interpretation, might be of assistance to GPs, or are
  10     you saying that really the only thing a GP should be
  11     seeking to do is to refer on to a competent
  12     paediatrician, who ought themselves to know best where
  13     next to send the child?
  14   A. I suppose it is a bit of both, really. In making
  15     a referral to a specialist colleague, the general
  16     practitioner is asking that specialist to undertake
  17     a consultation, therefore acting as a consultant,
  18     really, so he is speaking his or her advice on how to
  19     deal with a particular problem that may well be outwith
  20     his competence, or indeed may be seeking his reassurance
  21     that the abnormality is not an abnormality but is within
  22     the range of normal and does not need further treatment,
  23     so that is a reason for the referral from both the
  24     patient's point of view and the GP's point of view, but
  25     the GP, nonetheless, does not abrogate all

   1     responsibility for the patient in making a referral, and
   2     obviously it becomes a little more tenuous as the
   3     patient is referred up the specialist ladder, if you
   4     like, or on to tertiary care and so on, but obviously
   5     the GP does bear some responsibilities, and part of that
   6     is ensuring that the patient is aware of what is going
   7     on, helping the patient to interpret perhaps what he or
   8     she has been told in hospital, and so on. Again, there
   9     is an advocacy role, helping the patient to understand
  10     things. But particularly in very specialised areas like
  11     we are talking about, the GP really would not have the
  12     knowledge to make an assessment of an individual
  13     practitioner's competence in that way, I would suggest.
  14   Q. Is there any more information accompanied perhaps with
  15     specialist assessment that could be of assistance to GPs
  16     in this area, or have we arrived at a situation where
  17     the best they can do, and quite properly, is to pass
  18     them on to a consultant paediatrician?
  19   A. I think we probably are in that situation where it is
  20     necessary to consult with the paediatrician now. It may
  21     well be that that it is appropriate for the general
  22     practitioner to have some discussion, if not
  23     face-to-face then certainly over the phone, rather than
  24     just in written correspondence, to have some discussion
  25     with the consultant paediatrician about what is best for

   1     that particular patient, which again may be information
   2     about family circumstances and so on if, for example,
   3     the consultant paediatrician was referring to
   4     a particular course of action. I think that would be an
   5     important role, but in terms of the clinical need of
   6     that particular child, I think the GP would be obviously
   7     taking very strong steer from the paediatrician on
   8     that.
   9   Q. Does that mean that in effect the GP cannot really
  10     benefit or would not seek to obtain information about
  11     the comparative performance or outcomes in tertiary
  12     centres because of a reliance on the next stage up from
  13     their level of referral?
  14   A. I think, again, it would be variable. I think there is
  15     information that would usefully come through to general
  16     practitioners on many conditions and many procedures
  17     which are perhaps more common and which they are
  18     therefore referring more patients on. I think it does
  19     become more difficult when one is dealing with very
  20     small numbers and more infrequency.
  21   Q. If that is right, how can the GP use their knowledge to
  22     assist the patient to assess those things? They
  23     obviously have an important role, and have discussed it
  24     as the patient's advocate. What are they going to be
  25     able to do to assist the patients?

   1   A. Again, if they were uncertain about certain things that
   2     have been written or if the patient raises something the
   3     GP could not answer, that would be then when the GP
   4     would contact the paediatrician again and discuss it
   5     with them. If he or she could not interpret it at the
   6     time, he would actually again seek to consult with the
   7     specialist to try to get more -- and that does happen.
   8        I suppose it is perhaps part of the nature of the
   9     sort of medical school education I went through that
  10     very often unusual things do stick a little bit in your
  11     mind and, you know, would actually be of particular
  12     interest, so the GP would perhaps, as I say, refer back
  13     to the paediatrician and have, perhaps, a fuller
  14     discussion with the paediatrician about such an unusual
  15     situation than they would have done about something
  16     which was more commonplace.
  17   Q. If it is right that GPs would be able to derive very
  18     little benefit from information about tertiary centres
  19     because they so rarely encounter these particular
  20     problems, what hope is there, as it were, that parents
  21     will be able to derive benefit from such information?
  22     Is there any case for giving it to them?
  23   A. I think the first thing is, I do not think it is true of
  24     all tertiary procedures: I think there is a difference
  25     between much of the activity that goes on in tertiary

   1     centres and the very specialised nature as we are
   2     talking about here.
   3        I think again, there is a particular need, because
   4     of the rarity of the conditions and because of the
   5     difficulty that the average general practitioner will
   6     have in interpreting some of the information that would
   7     be available, I think it does put a particular onus on
   8     these very specialised centres and so on to have high
   9     quality information for patients, that is understandable
  10     to patients as well. It certainly has happened to me,
  11     I know it has happened to colleagues, for some rare
  12     conditions, with computerised technology and so on,
  13     patients will sometimes come in to the GP with something
  14     printed off the Internet or a patient Support Group that
  15     they have seen, because again, many rare conditions do
  16     have specialist associations, and in a sense, that is
  17     very appropriate, that the patient has a very real
  18     interest and a very natural interest in finding out as
  19     much as they possibly can about the condition, and that
  20     is appropriate, and it is appropriate that they discuss
  21     that with the GP. But for the general practitioner, it
  22     is part of a much bigger and wider workload, so the GP
  23     may well not have, and probably would not have, that
  24     very specialised interest in that particular case.
  25   Q. So the initiative must come from the specialist centres

   1     themselves to take the lead in developing ways of
   2     informing and assisting patients to understand the
   3     nature of their procedures and the role of the GP is to
   4     help the patient in talking through that, if you like,
   5     and then to pick up, to clarify, to explore on their
   6     behalf, areas that still remain doubtful or uncertain?
   7   A. I think that is probably largely true. I know that many
   8     specialist units do now produce literature and videos
   9     and patient information, which is very helpful. I think
  10     that if there is still doubt or the patient just has had
  11     no information and has not had the opportunity for
  12     discussion, I think that is where the general
  13     practitioner can contact the tertiary unit or the
  14     specialist unit seeking more information, so I do not
  15     think it is necessarily quite as passive as you painted
  16     it.
  17   Q. If I did so, it was unintentional.
  18   A. It sounded to me as if you are suggesting it is very
  19     much a one-way flow. I think it will be very often
  20     largely a one-way flow, but it need not be. The general
  21     practitioner can play a key role if he or she feels that
  22     the information has not been made available.
  23   Q. I think when I started on this line of questioning I was
  24     suggesting that there were perhaps two threads in
  25     paragraph 2.2.6. The first, I think I was trying to

   1     suggest, was the question of the availability of the
   2     specialist expertise.
   3   A. Yes.
   4   Q. The second, perhaps, though, is just information
   5     overload for GPs. Is there an issue about what use they
   6     can sensibly make of data such as hospital league
   7     tables, indicators of hospital performance, that are now
   8     possibly becoming or are about to become more generally
   9     available?
  10   A. Yes. I mean, we live in an age when there is lots of
  11     communication about very many things, and there is
  12     a huge amount of literature, much of it unsolicited,
  13     that arrives on the average GP's doorstep every day, so
  14     again I think the information that comes has to be
  15     relevant and it was relevant at the time it was needed,
  16     which of course can be a problem in itself.
  17        So I think, yes, there is a whole issue about
  18     that, and certainly, in the field of guidelines, for
  19     example, there is just an enormous amount of literature
  20     coming through that is impossible to absorb and
  21     incorporate.
  22   Q. If we can just go on to page 15 of your statement, you
  23     mention at paragraph 2.5.1 that a GP would expect to be
  24     quickly notified by a hospital and to respond
  25     appropriately in the case of the death of an infant or

   1     child.
   2        Then you mention that GPs undertake bereavement
   3     counselling for all age groups.
   4        Can I ask, is this provided as part of the NHS,
   5     first?
   6   A. Yes, it would be, yes.
   7   Q. And secondly, is it generally provided by the general
   8     practitioner himself, or would it be a question of
   9     referral to a specialist bereavement counsellor?
  10   A. For the majority it would be the GP or someone else in
  11     the primary care team, for example a health visitor,
  12     particularly if there had been a child involved and the
  13     health visitor had a good relationship with the family.
  14   Q. And that would be true throughout the period 1984 to
  15     1995, would it?
  16   A. Yes, it would have been, except that it was probably
  17     less developed. Again, this is an area where the
  18     medical profession and other health care professionals,
  19     it has developed over the years, so it is, I would hope,
  20     better now than it was a few years ago.
  21        I am just trying to think, exactly when.
  22     I suppose it was probably the late 1970s, the early
  23     1980s, that there began to be much more interest in this
  24     type of activity, but I can certainly check up on that
  25     in terms of timing.

   1   Q. I think it would be valuable if the College were to do
   2     that. When your statement says GPs undertake
   3     counselling for all age groups, it would be useful to
   4     have a sense of how true that has been throughout the
   5     period.
   6   A. Certainly much of the interest in this field has
   7     developed from the palliative care movement. I cannot
   8     off the top of my head remember when that really began
   9     to be more incorporated into day-to-day practice.
  10   Q. Certainly, looking at the pressure of time that is on
  11     many GPs, and the statistic of 8 minutes for the average
  12     consultation is widely used or heard, there might be an
  13     issue as to whether or not GPs had the time in their
  14     practices to give over to services such as bereavement
  15     counselling?
  16   A. Yes. I think again, to an extent it may depend on how
  17     you define the term "counselling". I think that many
  18     patients will be seen and very often visited at home by
  19     the GP at the time of the death, and that for many
  20     patients, or for many relatives of patients, it is not
  21     a continuing or ongoing process. Obviously there are
  22     certain situations where the relatives are encountering
  23     particular problems and so on and it may take longer,
  24     but I say again, for the majority of GPs I would think
  25     this would be undertaken as a home visit, that sort of

   1     thing. So the time constraint is still there, but not
   2     quite the same as when there is a patient waiting
   3     outside to be seen.
   4   Q. Is that perhaps what lies behind the word
   5     "appropriately", because you say that a GP would
   6     respond appropriately in the case of a death? What is
   7     an appropriate response to notification by the hospital
   8     of such an event?
   9   A. Again, it will vary and different practitioners and
  10     different practices will have different responses,
  11     I suspect, but certainly it would seem appropriate to --
  12     I am sure many GPs do -- make contact with the family at
  13     a suitable time after the death; that they would most
  14     probably offer their sympathies and those of others that
  15     have perhaps been dealing with the patient or the child
  16     that had died, and that they would discuss future
  17     contacts and so on. Again, it would depend on the time
  18     available and funeral arrangements and things like that
  19     again. Again, it is the balance of not wanting to be
  20     too obtrusive at a time of great grief and the family
  21     knowing the general practitioner is there for support as
  22     well.
  23   Q. Generally the general practitioner, as a matter of good
  24     practice, would be the one to make the initial contact,
  25     rather than waiting for the family to contact their

   1     surgery?
   2   A. That would certainly be my practice, yes.
   3   Q. Does that mean that if families may, for instance, tell
   4     the Inquiry that nobody offered them bereavement
   5     counselling, then perhaps it might be suggested, it
   6     might be a problem of definition here, that contact from
   7     a GP, a home visit, might not be seen as counselling,
   8     even if it was intended by the GP to provide that form
   9     of support?
  10   A. Yes, I think that is probably true. Again, of course,
  11     it is how much has been picked up. The GP may have made
  12     contact and may have said something like, "Well, you
  13     know, once the funeral is over, and so on, please make
  14     contact with me", and that has not been heard in quite
  15     the way that the GP had intended or picked up, because
  16     there are so many other things on the minds of the
  17     families, sadly.
  18        I think the particular embarrassing situation for
  19     GPs is -- or indeed nursing staff, very often -- where
  20     someone has died in hospital, not necessarily a child
  21     but perhaps an adult, and the practice has not been
  22     notified. That, unfortunately, does happen.
  23   Q. Thank you. Just finally, one further question and that
  24     is the question of the retention of parts of the body
  25     after postmortems. It is something that occurs on

   1     occasion, and it is something that possibly members of
   2     the College have had to deal with in dealing with
   3     families who are addressing this situation as part and
   4     parcel of the experience of a postmortem, or possibly
   5     because they learn this has taken place at a later date.
   6        Is this something that comes within the experience
   7     of the College or yourself?
   8   A. It has not done, in a general sense it would be an issue
   9     that would be discussed by our Ethics Committee in
  10     a general sense. I can see and understand that it would
  11     be very distressing for parents to find out that tissue
  12     had been kept without their knowledge, and I think the
  13     key issue would seem to be the one of informed consent
  14     and that if it is intended to retain tissue after
  15     a postmortem, either for research purposes or teaching
  16     or other -- for further investigation or further
  17     examination, I would have thought it important that that
  18     is explained to the parents at the time, rather than
  19     find out subsequently.
  20   Q. Do you yourself have any experience of how parents react
  21     in being faced with such a discussion and such a dilemma
  22     for them giving their permission or not?
  23   A. Not on retention of tissue, but I have had experience of
  24     hearing from hospital colleagues where even the
  25     discussion of the postmortem itself is one that

   1     distresses many people, and if someone has died suddenly
   2     but obviously has the criteria that one can issue
   3     a death certificate, often relatives express relief that
   4     a postmortem is not required, so I think, and again it
   5     is understandable, but I think there is fear in some
   6     ways of such procedures.
   7   Q. Does that in turn then, as part of what you are saying,
   8     impact upon the reluctance or possible reluctance to
   9     discuss these matters openly with parents or relatives?
  10   A. It may, but it should not. It is a very difficult issue
  11     and there are difficulties in discussing it, but they do
  12     still need to be discussed.
  13   MISS GREY: Thank you. Dr Reith, I have been asking
  14     a number of questions over almost a two-hour period.
  15     Can I ask you: is there anything that you would like to
  16     tell the Inquiry about, to draw to our attention, that
  17     has not already been covered throughout the discussion
  18     we have been having this morning?
  19   A. There is nothing else that I am aware of that would be
  20     supplementary to our written evidence, or indeed to the
  21     questioning this morning. Just to say, if anything, as
  22     the Inquiry unfolds, if there is anything that we can
  23     help by providing information or whatever publications,
  24     we are certainly happy to do that, and obviously one of
  25     the things that has come up today is the issue of

   1     records of hospital visiting and BRI and just to confirm
   2     we will obviously be as helpful as we possibly can to
   3     the Inquiry.
   4   MISS GREY: We would be grateful for that, and also we
   5     touched upon this morning the question of coming back to
   6     us on the subject of good practice on bereavement
   7     counselling. Thank you very much. The Panel may have
   8     some questions for you.
   9             EXAMINED by THE PANEL:
  10   MRS MACLEAN: Earlier on this morning, Miss Grey was
  11     directing a number of questions to the issue of whether
  12     it would be useful for general practitioners to have
  13     information from specialist hospital services about the
  14     outcomes of care provided there. I just wanted to check
  15     that I understood the debate correctly. I thought that
  16     your response was indicating that you thought that this
  17     would not be helpful in cases of very rare conditions
  18     such as the particular heart defects with which we are
  19     concerned here. I found that confusing because my
  20     expectation would have been the other way: that where
  21     you are dealing with a common condition your local
  22     knowledge will tell you where things go well, where
  23     perhaps they might go less well, and that it might be
  24     with the more rare conditions that it might be more
  25     important for you to have some information coming to you

   1     from a hospital, in that your own experience, your own
   2     local knowledge, will be more limited. If you can
   3     clarify for me, I would be grateful.
   4   A. Yes. Again, it is the nature of the information.
   5     I think that if the information coming from the hospital
   6     is about the nature of the condition and the management
   7     and possible complications and so on, that that is
   8     helpful and particularly helpful in rare conditions,
   9     because you are correct that those are things where
  10     developments may happen at a pace that does not come up
  11     in textbooks and things. So I think information about
  12     the progress that a particular patient is likely to take
  13     is very helpful. Now many hospitals do, as I say, have
  14     information sheets and so on.
  15        I think where the information is less helpful --
  16     this is really what I was trying to tease out, and my
  17     apologies if not successfully -- was that statistical
  18     information about individual performance on procedures
  19     that are very rare is difficult for the GP to interpret,
  20     that if in this case for example there was a complex
  21     cardiac procedure undertaken and that is put into some
  22     sort of context about what a particular specialist's
  23     success rate or otherwise is, if the next time
  24     I encounter anything like that problem is five to ten
  25     years later when clinical practice will have changed

   1     probably considerably, it does not relate back to that.
   2        Does that clarify it?
   3   Q. That is very helpful, thank you.
   4   THE CHAIRMAN: Professor Jarman?
   5   PROFESSOR JARMAN: I just wanted to develop that last
   6     point. You have emphasised, and the documents emphasise
   7     that our job as GPs is to act as the patient's advocate
   8     and that there is at times very little objective
   9     information. The interviews with consultants would not
  10     be very available to the average GP, it is only local
  11     knowledge. But if the information were of more common
  12     conditions in which the number of cases were sufficient
  13     for you to have confidence in the data and if there were
  14     adjustment for case mix which you mentioned, would you
  15     then think that information would be helpful for general
  16     practitioners?
  17   A. Yes, very much. I think that was the point I was trying
  18     to make between the common and the rare. That the more
  19     common conditions would be obviously of more day-to-day
  20     relevance, if you like, to the GP.
  21   PROFESSOR JARMAN: Thank you very much.
  22   THE CHAIRMAN: Dr Reith, when Professor Jarman said "our
  23     job" he was referring to the solidarity of GPs I think.
  24     Our job on the Panel is somewhat different. I just
  25     point that out for the record.

   1        We are very grateful to you for coming this
   2     morning. You have come a long way and we have been much
   3     assisted by what you have had to say. I reiterate that
   4     you can contact us whenever you wish.
   5        Two matters have come up which you have offered
   6     your assistance on, but we are also grateful for your
   7     offer in general of continued help, and that is very
   8     important to us, to receive further thoughts from time
   9     to time from you and others.
  10        For this morning, we have nothing else, save for
  11     me to repeat again, our thanks. If you could bear with
  12     us for one moment while we listen to Mr Langstaff, then
  13     we can withdraw.
  14   MR LANGSTAFF: Sir, at 10.30 tomorrow morning -- I should
  15     perhaps repeat that time, because it is, as was today,
  16     away from our usual pattern -- at 10.30 tomorrow morning
  17     we will have the advantage of hearing from Professor
  18     Sir Terence English, whose name has featured in the
  19     other strand of evidence we have been hearing in
  20     Block 2, that is the evidence from the Home Office (sic)
  21     and the Welsh Office, in relation to the Supra Regional
  22     Services Advisory Group, the designation as
  23     a supra-regional service of neonatal and infant cardiac
  24     surgery in Bristol and its de-designation with effect
  25     from 1st April 1994.

   1        He will be the only witness that we will have
   2     tomorrow. Our expectation is that he may take well into
   3     the afternoon, but how far depends very much upon the
   4     way that the evidence goes.
   5        I do not want to anticipate too much of next week,
   6     but it may be helpful to say that on Monday -- this is
   7     really again giving advance notice to those in the wider
   8     audience -- we will begin by hearing from Professor Baum
   9     of the Royal of Paediatrics and Child Health.
  10   THE CHAIRMAN: Mr Langstaff, thank you. You mentioned the
  11     Home Office. I think you meant the Department of
  12     Health?
  13   MR LANGSTAFF: I did. You are absolutely right to correct
  14     me and I am very grateful. I had it in mind that we
  15     started the Inquiry with the parents and we have moved
  16     from Bristol towards Whitehall, and that is what was in
  17     my mind. You are absolutely right to correct me.
  18   THE CHAIRMAN: Yes, indeed. That has in fact been a feature
  19     that we have sought to, as it were, trace from the
  20     particular back to the general at policy level, and we
  21     will suddenly find in Block 3 and Block 4 that we will
  22     return back to the particular in Bristol. So I am
  23     grateful to you for identifying that.
  24        We will adjourn until tomorrow at 10.30. Again,
  25     thank you very much.

   1   (12.50 pm)
   2     (Adjourned until 10.30 am on Thursday, 13th May, 1999)
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   6                I N D E X
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   8     DR WILLIAM REITH (Sworn)
   9
  10        Examined by MISS GREY ......................... 1
  11        Examined by THE PANEL ......................... 65
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001