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 Hearing summary 29th MARCH 1999   The second block of evidence continued today, looking at the national scene, which will include evidence from the Department of Health, witnesses from the Supra-Regional services, Royal Colleges and professional organisations.   Dr Susan Jones, former President of the Association of Paediatric Anaesthetists of Great Britain and Ireland (IPA) gave evidence to the Inquiry today. She stated that where children and adults were cared for in a mixed setting, the children would receive second-best treatment, observing that critically ill children have more in common with other children than with adults with a similar illness. Dr Jones described the process of training for anaesthetists following general professional training, saying that at least 12 months paediatric experience would be anticipated from applicants for paediatric anaesthesia posts and 6 months for mixed posts. Dr Jones went on to describe audit practice during the period of the Inquiry terms of reference. Her final evidence related to communications between anaesthetist and patient/family and between anaesthetist, surgeon and physician.   Dr Paul Lawler, President of the Intensive Care Society, described the process, known as Apache II (Acute Physiology, Age and Chronic Health Evaluation), by which ICU (Intensive Care Unit) staff are able to project the likely outcome for patients, based on the severity of the patients illness at 24 hours after admission. He stressed that Apache II should not be applied to children under 16 years of age. However, an alternative, PRISM (Paediatric Risk of Mortality) is in use, but is less well validated. He went on to discuss the definition of closed and open ICUs in terms of consultant responsibility for patients. Dr Lawler then described the use of Cusum analysis, which is a statistical method using clinicians’ outcomes against a given failure rate to determine acceptable levels of failure. He continued by telling the Inquiry about ICU nurse training and staffing requirements and concluded by commenting on the location of ICU wards in relation to other facilities, highlighting the need for relatives’ rooms to be adjacent to the unit.

FULL TRANSCRIPT

   1     Day 8, 29th March, 1999
   2   (10.30 am)
   3   MISS GREY: Good morning. Sir, our first witness today is
   4     Dr Susan Jones, who is speaking on behalf of the
   5     Association of Paediatric Anaesthetists. If I could
   6     invite her, please, to come to the witness stand.
   7        Dr Jones, I think it has been explained to you
   8     that we are proposing to take evidence on oath
   9     throughout this Inquiry. Could I therefore invite to
  10     you stand whilst you take the oath?
  11           DR SUSAN E.F. JONES (Sworn):
  12             Examined by MISS GREY:
  13   Q. Dr Jones, you have made a statement to this Inquiry
  14     already. If I could just invite that to be put up on
  15     screen, please, it is witness 72/1.
  16        That, I think, should be the first page of the
  17     statement you have given to the Inquiry. At the back of
  18     it, page 4, if we could have that on screen, please, is
  19     your signature. Is that correct?
  20   A. It is.
  21   Q. If I could just take you back, please, to page 1 of the
  22     document, that sets out, at the front, your
  23     qualifications and your current position at the
  24     Department of Anaesthesia in the Birmingham Children's
  25     Hospital Trust.

   1        Dr Jones, is it right that you are now the
   2     President of the Association of Paediatric
   3     Anaesthetists?
   4   A. No. As from two weeks ago, I became the past
   5     President. I handed over to my successor two weeks ago,
   6     at our annual scientific meeting, but at the time
   7     I wrote the statement, I was.
   8   Q. But I think you are happy to come today to talk on
   9     behalf of the Association, nonetheless?
  10   A. Yes.
  11   Q. We are proposing, if we may, to take your statement as
  12     read, but then to ask you various supplementary
  13     questions throughout the course of this particular
  14     session.
  15        Could I just invite you, please, to describe
  16     a little the work of the Association of Paediatric
  17     Anaesthetists. It was founded in 1973?
  18   A. Yes.
  19   Q. What factors led to the awareness that paediatric
  20     anaesthesia was a separate specialty or particular area
  21     of professional interest?
  22   A. The Society, as you say, was founded in 1973, and it was
  23     a group of about, in those days, perhaps 20/25 dedicated
  24     (in terms of full-time) paediatric anaesthetists who
  25     decided to get together and form another professional

   1     association purely of full-time paediatric
   2     anaesthetists. They set this up in -- they actually met
   3     in Bristol in 1973, set up the organisation, wrote
   4     a constitution, et cetera. I think this was a belief
   5     that paediatric anaesthesia was moving in parallel with
   6     paediatric surgery towards having full-time
   7     practitioners, by and large. There would always be room
   8     and in fact a need for people who only practised
   9     half-time paediatric anaesthesia and half-time adult
  10     anaesthesia that there was a need to have some core
  11     values, as it were, and to be able to discuss in more
  12     depth the scientific and practical aspect of paediatric
  13     anaesthesia.
  14        It has taken off from there, and as I say, we now
  15     have nearly 400 members.
  16   Q. Can you tell the Inquiry a little about the specific
  17     technical challenges that would be specific to the
  18     discipline of paediatric anaesthesia as opposed to
  19     generalist adult anaesthesia?
  20   A. I think the first thing that must be obvious, surely, to
  21     everyone, is the size of the patient, and, I mean,
  22     children come in all shapes and sizes but the actual
  23     smallest patients, the babies, the prem babies as well,
  24     are the most technically challenging. They are
  25     difficult to anaesthetise because they are small. They

   1     have different physiology and different requirements of
   2     drugs and intravenous fluids, all sorts of things like
   3     that. One has to be very, very careful, as it were,
   4     when dealing with these small infants. It is the small
   5     child and the baby in particular that presents the
   6     challenge, and, indeed, is the reason -- the usual
   7     reason why most of us do paediatric anaesthesia, not to
   8     be dealing with the much larger child.
   9        The older child, sort of above five or six,
  10     especially having a fairly minor -- a well child having
  11     a routine operation, is probably not outwith the
  12     capacity of any sensible anaesthetist to deal with.
  13   Q. So the particular challenges arise in the management of
  14     children from birth to approximately five years of age?
  15   A. Certainly, that is the most obvious, but after that, of
  16     course, a lot of the children you deal with have
  17     congenital abnormalities and multiple congenital
  18     abnormalities which require not just surgery but a lot
  19     of other medical sort of expertise as well. They often
  20     have on-going problems that require continuous treatment
  21     up to the time they become adults, and then they often
  22     have to go on after that, as well.
  23        I think that even the larger child, as well, with
  24     complex congenital disease, requires a different
  25     approach from the average adult who becomes suddenly

   1     ill.
   2   Q. Before you go any further, Dr Jones, can I just check
   3     that your evidence is audible to the Panel? (The Panel
   4     indicate it is)
   5        You have spoken briefly of what you might call the
   6     technical or medical difficulties in managing very small
   7     children, but in your witness statement -- I am looking
   8     at page 4 of the statement, please, at paragraph 4.2 --
   9     you also speak of the need for "adequate and appropriate
  10     training and this involving not merely anaesthetic
  11     techniques, but a real understanding of the needs, both
  12     physical and emotional, of the child and his/her
  13     parents."
  14        Could you explain a little further what you mean
  15     by that?
  16   A. Perhaps if you look at the physical side of things, as
  17     I said, a lot of the children have multiple problems,
  18     a lot of them have special needs and on-going congenital
  19     problems that require surgery over a long period of
  20     time. One does not see those in the adult population,
  21     who mostly have acquired disease and requires an
  22     in-depth understanding of the underlying medical
  23     conditions of a lot of these children.
  24        Similarly the emotional needs. You are not just
  25     dealing with a child; you are dealing with the whole

   1     family, really. The child is not actually consenting to
   2     the operation, it is the parents who consent on behalf
   3     of their child. I think that this requires
   4     a considerable amount of understanding. You are
   5     actually looking after that child on behalf of the
   6     parents, but you must take this into account in
   7     everything you do.
   8   Q. That is something which is important for an anaesthetist
   9     to have an understanding of?
  10   A. Absolutely.
  11   Q. As well as say a nurse who has day-to-day encounter with
  12     the child and its parents?
  13   A. Absolutely.
  14   Q. Your own practice, I think, covers both the fields, or
  15     you have anaesthetised in a number of operations,
  16     including cardiac surgery. Is that representative of
  17     the practice of the members of the Association of
  18     Paediatric Anaesthetists, or not?
  19   A. I would say that we have a membership, a home membership
  20     of over 200 people, of whom about 60 per cent would be
  21     full-time paediatric anaesthetists, so you are looking
  22     at over 100, just over 100 people.
  23        I would say only something like a quarter of those
  24     actually do paediatric cardiac anaesthesia. Everybody
  25     will do a mixture of all sorts of types of surgery and

   1     anaesthesia, but not an awful lot of people will do
   2     cardiac anaesthesia.
   3   Q. How do the requirements of paediatric cardiac
   4     anaesthesia differ from those of anaesthesia across more
   5     general surgical specialities or other surgical
   6     specialities?
   7   A. I think again, it is technically quite a difficult
   8     problem, or difficult branch of paediatric anaesthesia.
   9     Also, again, there is a need for a deep understanding of
  10     the actual congenital abnormalities that these children
  11     have, and the physiology of the circulation, the lungs
  12     as well, that is brought about by these changes in the
  13     abnormal heart.
  14        So I think there is an in-depth understanding of
  15     that. Similarly, the anaesthesia must very much
  16     parallel the cardiac surgery, in that there are sort
  17     of -- you have to be knowing exactly what is going on in
  18     the surgical field to be able to deal with the difficult
  19     moments, going on bypass, coming off bypass, how to deal
  20     with the failing heart, all this sort of thing, requires
  21     quite a considerable amount of training and then
  22     experience to deal with this. It would not be within
  23     the field of the majority of paediatric anaesthetists.
  24   Q. That is obviously an area you are familiar with from
  25     your practice, but coming here today, speaking as past

   1     President of the Association of Paediatric
   2     Anaesthetists, is that something you feel able to speak
   3     to, or is it something that, because of the fact that
   4     only perhaps a quarter of the Association's members deal
   5     with, you feel is outside the scope of your evidence
   6     today?
   7   A. I feel that I have come here, really, to represent our
   8     Association and our members. I feel that if I was to
   9     talk about cardiac anaesthesia, this would be a personal
  10     view, and I do not think I have been invited on those
  11     terms. Obviously if it impinges, if it elucidates or
  12     elaborates a bit, that is fine, but not specifically,
  13     I do not think.
  14   Q. If we could then trace, perhaps, the recognition in the
  15     standards of anaesthetics in hospitals of the particular
  16     place of paediatric anaesthetists, could I invite you to
  17     speak of the time-scale in which it was first recognised
  18     there was a particular place for paediatric
  19     anaesthetists with a particular understanding of the
  20     anatomy of challenges posed by young children?
  21   A. As I say, our Association was founded in 1973, so
  22     presumably that was, if you like, a reference point, in
  23     that an awful lot of people got together and decided to
  24     form the Association. But nearly all these were already
  25     full-time paediatric anaesthetists, so presumably,

   1     before that, there had been an awareness coming on.
   2     Certainly, some of the earlier published work dated from
   3     the early 1950s, so presumably since the war there has
   4     been, among certain people, an awareness that certainly
   5     the smaller child was perhaps a different person to the
   6     older child, and indeed to the adult and therefore
   7     required a different way of dealing with it.
   8        I would certainly say the early 1970s were the
   9     time where people became very much aware that -- it was
  10     the time of a certain degree of expansion, and certainly
  11     in the 1980s there was a major expansion in the number
  12     of consultant posts within paediatric anaesthesia and
  13     paediatric surgery.
  14   Q. If there was an awareness amongst members of the
  15     profession that there was this particular specialty and
  16     that children should have the services of the specialist
  17     paediatric anaesthetist, was that something which, at
  18     that time, was reflected in professional standards or
  19     guidelines, or was that a matter of professional
  20     recognition only?
  21   A. I think it is professional recognition only. I think
  22     that -- sort of recommendations, guidelines, standards
  23     and enforcement of these has always been in anaesthesia,
  24     and I think in other branches of medicine, the remit of
  25     the GMC and the Royal Colleges. I think it would be

   1     either invidious or not appropriate. It may be
   2     different in the future, but up to now it has not been
   3     appropriate that other professional organisations should
   4     set themselves up as sort of experts in producing
   5     standards. It could potentially cause problems. Which
   6     is not to say, of course, that people should not have
   7     standards to aspire to, even if they are unwritten, and
   8     that there is a philosophy, of course. Every Society
   9     should have a philosophy which the people who belong to
  10     it should aim for.
  11   Q. If I could take you to written standards to which people
  12     might aspire to, could I take you to the National
  13     Confidential Enquiry into Peri-operative Deaths which
  14     reported in 1989? Could we look, please, at CPOD
  15     file 1, page 13, where we should see, please, on our
  16     screens the general conclusions of the study of the
  17     Inquiry which reported in 1989. Obviously the first
  18     conclusion was that the overall surgical and anaesthetic
  19     care of children as revealed to this enquiry is
  20     excellent.
  21        They went on to say that most surgery and
  22     anaesthesia for children was given by clinicians with
  23     regular paediatric practice, but that was not always so.
  24        If we turn over the page to the recommendations on
  25     page 14, recommendation 4 was that surgeons and

   1     anaesthetists should not undertake occasional paediatric
   2     practice. "The outcome of surgery and anaesthesia in
   3     children is related to the experience of the clinicians
   4     involved."
   5        Was that a conclusion supported by the profession
   6     at that time?
   7   A. Yes, certainly in anaesthesia -- well, by the vast
   8     majority of anaesthetists, anyway.
   9   Q. If I could take you, please, to page 120 of that report
  10     and to the base of the report under "cardiac deaths",
  11     two paragraphs, 70 per cent of the children were managed
  12     by anaesthetists who were in regular current practice
  13     amongst children. They mention two deaths after cardiac
  14     surgery in university hospitals in which the consultant
  15     anaesthetists claimed that they were responsible for 10
  16     infants and 10 children in the previous year.
  17        How would that strike you as a level of experience
  18     in anaesthetising children?
  19   A. Whether they are children -- whichever kind of operation
  20     that is too little, really. That is only 20 patients in
  21     one year.
  22   Q. That is the theme that has been teased out by that
  23     paragraph of that report, but that is a very low number
  24     of children to be anaesthetising.
  25        If we can turn back to table A9 at the bottom of

   1     page 119, you can see there the table to which that
   2     paragraph has referred, where there are two deaths
   3     amongst the cardiac category, amongst anaesthetists who
   4     are anaesthetising between one and 19 children in the
   5     previous year.
   6        Then in the index column, the control cases where
   7     there were no deaths, there appear to be a substantial
   8     number of cases in which only a small number of
   9     children, again, are being anaesthetised.
  10        The study was teasing out or looking at the number
  11     of operations that were carried out on children, where
  12     there had only been a small amount of paediatric
  13     anaesthesia carried out in the previous year. When it
  14     concluded that the outcomes were affected by that level
  15     of paediatric experience, was that something that was
  16     well known before that particular study?
  17   A. I think people had always assumed that the more patients
  18     you did with a particular condition or nature, the more
  19     you did all the time, the better you were at it and
  20     therefore one would assume, the better the outcome.
  21   Q. When CPOD drew the same conclusions, were they
  22     conclusions that were widely accepted in the profession,
  23     or were there any concerns about the CPOD methodology
  24     that might undermine those conclusions?
  25   A. I think they were well accepted by the people who had

   1     actually returned their forms, but of course this was
   2     a voluntary sort of study; there was no compulsion for
   3     people -- well, deaths were always reported, but
   4     certainly, quite a few deaths had never got
   5     investigated; people either forgot or did not send their
   6     forms back in.
   7        So perhaps the numerate is a bit small in a lot of
   8     these. Nevertheless, one would assume from the
   9     non-returns that those could not have been awfully good
  10     results. I think perhaps they did not bear scrutiny.
  11     That was just a personal view, but I think, therefore,
  12     that one can draw fairly reasonable conclusion from the
  13     CPOD report, and I think most people did.
  14   Q. When it concluded paediatric anaesthesia should not be
  15     undertaken by those who had only occasional experience
  16     in the field, what was the reaction of the APA, or,
  17     indeed professional anaesthetists, to that conclusion?
  18   A. I think the APA certainly supported that conclusion.
  19     I think the majority of sensible anaesthetists supported
  20     that conclusion, and indeed, since that time, I think
  21     a lot of anaesthetists, it has acted as a catalyst, the
  22     CPOD report, and an awful lot of anaesthetists have
  23     flatly refused to anaesthetise small children and
  24     infants if they felt it was outside their competence.
  25     They have insisted the children are moved to a more

   1     appropriate centre.
   2   Q. You have used the word "catalyst". Is that appropriate,
   3     because the recommendation was drawing attention to
   4     something that was already known but which people had
   5     not had the authority or the support in deciding that it
   6     therefore meant that they should not be anaesthetising
   7     children if they only had occasional paediatric
   8     experience?
   9   A. Yes, I think that is a fair comment.
  10   Q. CPOD had recommended that you should not undertake
  11     paediatric anaesthesia if you had only occasional
  12     experience in the field. Are you able to help us, then,
  13     on the implementation of that recommendation, because it
  14     was not, I understand, an immediate event after CPOD had
  15     reported?
  16   A. No. I think that they were recommendations; they were
  17     not totally enforceable. I think it just gave people,
  18     any sensible thinking people, a document to which they
  19     could refer and say, "I think we should move these
  20     children. I think we should plan to move these
  21     children. I do not think we should be doing these in
  22     our hospital any more."
  23        Subsequently, there have been several other
  24     documents which continue this sort of theme. I am sure
  25     you will refer to them. Those again followed, I think,

   1     from the CPOD report. It is not enforceable, or has not
   2     been.
   3   Q. The counter-argument was that it might be dangerous to
   4     transfer children who were in a DGH, let us say, and
   5     might require transfer to a specialised area, if they
   6     were to have the services of a paediatric anaesthetist?
   7   A. I think that was just an excuse. Children are moved
   8     large distances in quite critical conditions. I do not
   9     think there is any bar to moving children or babies if
  10     they are ill, provided there has been a degree of
  11     resuscitation beforehand.
  12   Q. So the key, therefore, is a degree of resuscitation?
  13   A. Yes.
  14   Q. And possibly the level of support or the facilities made
  15     available to a child on transfer to a more specialised
  16     centre?
  17   A. It was always a weak point, the transfer services.
  18     Nowadays one has much better retrieval teams where the
  19     team goes out from the tertiary centre or wherever and
  20     goes to collect and resuscitate the patient they are
  21     going to move, rather than just the local people having
  22     to cope and then transfer the patient.
  23   Q. You say "nowadays"?
  24   A. Well, within the last two or three years. There are
  25     certain hospitals who have always had retrieval teams,

   1     and indeed, the neonatologists for many years have had
   2     retrieval teams, but in paediatric intensive care in
   3     particular, which many of these patients will be
   4     referring to, they come into that category: there have
   5     not been true retrieval teams. But there are a lot more
   6     of them around now.
   7   Q. You are painting a picture, before a couple of years
   8     ago, of a fairly fragmented service or a situation in
   9     which it would be difficult to generalise about the
  10     level of service provided by different units?
  11   A. It is difficult to generalise and I would not say it was
  12     fragmented, but there was a great will to do a lot of
  13     these things, and endless working parties and endless
  14     reports on what one should be doing. The actual did not
  15     seem to happen, put it that way.
  16   Q. If I could take you back to one of those working parties
  17     on the subject of transfer, this is the British
  18     Paediatric Association report of the Joint Working
  19     Group, February 1993. If we could look at witness 72,
  20     page 5, if we could have that on the screen, that is the
  21     title page of the document. If we could look at page 7,
  22     the membership of the Working Group is set out there.
  23     In fact, it is Peter Morris who is the member from the
  24     Association of Paediatric Anaesthetists.
  25        If one could look at page 8, looking at

   1     paragraph 1.7, we see there that in the CPOD report
   2     concern was expressed about peri-operative mortality in
   3     units which only occasionally treated children.
   4        Then there is a reservation as to the extent of
   5     the evidence that was backing up that conclusion and the
   6     extent of the evidence that was supporting differences
   7     in outcome for different units at that time.
   8        Does this reflect a continued debate on the
   9     differences in outcome if children were managed by
  10     paediatric anaesthetists?
  11   A. I think that particular paragraph is really looking at
  12     surgery, is it not? I mean, it may well be relevant.
  13        I think what they are looking at there is the
  14     difference between the true specialist paediatric
  15     surgeon working specifically only with children, and
  16     maybe in a big tertiary referral centre, and a surgeon
  17     maybe in a DGH or University Hospital who has an adult
  18     practice as well, but they have paediatric expertise,
  19     that is, that they have, in some areas, considerable
  20     experience with children.
  21        I am not sure why they are making that comment,
  22     actually.
  23   Q. If we could drop down, then, please, to the bottom of
  24     the page, the issues for the Working Party are set out
  25     at 1.9 there, which children would benefit by transfer

   1     to a specialist children's surgical unit and what is
   2     necessary to provide a competent surgical service for
   3     children in a district hospital.
   4        If we turn to page 14 of the document, to
   5     paragraph 6.2, it is apparent, is it not, that in
   6     a sense cardiac surgery was standing outside this debate
   7     because it was not conceivably a general surgical
   8     service that could be provided by a district general
   9     hospital?
  10   A. That is right.
  11   Q. So in this field, no-one doubted that children with
  12     cardiac lesions, congenital heart problems, did need
  13     transfer to a specialist centre and therefore the
  14     question of their transfer and the arrangements that
  15     should be made for it were not the direct subject matter
  16     of this particular report; is that right?
  17   A. Yes.
  18   Q. If we look, however, at page 13, of the report, this is
  19     the consultant anaesthetic services for children in
  20     a district hospital. At the bottom, recommendation 2,
  21     they spoke of the need to have on the staff a consultant
  22     anaesthetist responsible for the anaesthetic services
  23     for children.
  24        Was that a recommendation that you understood as
  25     being appropriate to the specialised unit where they

   1     were treating children for cardiac lesions, or is this
   2     a recommendation that would only be appropriate for the
   3     less specialised service for children in the district
   4     hospital?
   5   A. I have always understood it applied to both.
   6   Q. So therefore, there was an obvious need to have
   7     a specialised consultant, paediatric consultant
   8     anaesthetist nominated to consultant anaesthetist, at
   9     such a specialised centre as well?
  10   A. Anywhere that children are operated on and anaesthetised
  11     should have a consultant anaesthetist in charge of
  12     paediatric anaesthetic services.
  13   Q. But can you help us a little bit further upon what was
  14     meant there for, first of all, anaesthetic services for
  15     children? What age of children were being referred to
  16     as being those who needed the services of a specialised
  17     consultant paediatric anaesthetist?
  18   A. I think the thing here is, it says "in every hospital",
  19     so it could encompass absolutely every DGH; it could be
  20     anywhere. But, you know, in a DGH you may anaesthetise
  21     children from one year up to 16; they are all children.
  22     They all still require somebody to supervise the
  23     anaesthetic services that are delivered to them.
  24   Q. It is a difficulty, I think, in working from this
  25     report, which, as we have noted, was not directly

   1     concerned with the more specialised centres carrying out
   2     cardiac work, because the recommendation there, let me
   3     take you to it for the sake of completeness, is in fact
   4     at page 15, where they talk about the structure of
   5     a specialist children's surgical service, but conclude
   6     in paragraph 6.7 that:
   7        "It is not the purpose of this report to comment
   8     on how many centres there should be or where they should
   9     be sited nor on the staff compliments or resources of
  10     those in those places."
  11        So in a sense this report was not directly
  12     concerned with the units say comparable to that at
  13     Bristol where you had children undergoing cardiac
  14     surgery. But what I was nonetheless seeking to elicit
  15     from you, if you can help us, is what the framework or
  16     the definitions or parameters for a consultant
  17     paediatric anaesthetist would be at such a centre, and
  18     first of all, in relation to the age of the children
  19     with whom they would be specifically concerned?
  20   A. Are you talking now about specialist centres that deal
  21     with everything from 0 to 16 years?
  22   Q. I am talking about the specialist centre which would
  23     undertake both adult and paediatric work, but was
  24     concerned to ensure that paediatric children had
  25     a specialised paediatric service.

   1   A. I think, as I said before, the report actually indicates
   2     in every hospital and that would include these
   3     hospitals, there should be somebody. In fact the Royal
   4     College of Anaesthetists recommends that there is
   5     a consultant in charge of anaesthetic services for
   6     children in any hospital where children are
   7     anaesthetised.
   8   Q. So there should be someone in charge, people with
   9     nominated responsibility for children's anaesthetic
  10     services in charge of a particular unit?
  11   A. Yes.
  12   Q. Would that person also be responsible for ensuring that
  13     those who undertook the anaesthesia of children for
  14     surgery should have the relevant paediatric experience
  15     as well?
  16   A. Oh, yes, I think so.
  17   Q. What would the mechanics be of ensuring that that
  18     relevant experience was attached to particular surgical
  19     procedures at the right time?
  20   A. That could be difficult. I think the other thing, of
  21     course, is that people who are appointed to, for
  22     instance, if we are talking about the Bristol services,
  23     you are talking about anaesthetists who anaesthetise,
  24     who do cardiac anaesthesia in adults and children, and
  25     no doubt, at the time they applied for the jobs, those

   1     people were able to demonstrate a training in both
   2     paediatric anaesthesia and in paediatric cardiac
   3     anaesthesia. I think no-one in their right mind would
   4     undertake a job where they had no training in paediatric
   5     cardiac anaesthesia, whether or not it had been in
   6     a specialist children's hospital where they had big
   7     throughput of cardiac cases, or whether or not it was in
   8     a similar sort of institution, mixed adults and
   9     children, I do not know. But I think generally, the
  10     people applying this -- there is a bit of self-selection
  11     here. You would not apply for that job unless you felt
  12     and were able to demonstrate confidence in
  13     anaesthetising children for cardiac surgery.
  14   Q. So there would be a basic level of competence
  15     demonstrated by past training. How would you go about
  16     ensuring that level of competence was maintained?
  17   A. I think it is important that people belong to
  18     appropriate societies and go to meetings, to consultant
  19     update days, refresher courses, things like this, in
  20     order to keep up to date. The majority of people do try
  21     to do that anyway, as long as the demands of the service
  22     do not get in the way.
  23   Q. If we can come back to the question of continued
  24     professional education later, the question I was seeking
  25     to ask was, what level, what number of operations, or

   1     number of anaesthetic procedures, would someone
   2     practising within the field of consultant paediatric
   3     anaesthesia need to be involved in on a weekly basis, in
   4     order to, as it were, keep their hand in at that
   5     particular field of specialism?
   6   A. I think it depends what subject they are doing. For
   7     instance, cardiac operations take a long time. If they
   8     were in a mixed adult and children's unit I think they
   9     ought to be doing one a week on an elective basis,
  10     probably more if they are covering for another colleague
  11     and possibly more if they are doing emergencies as well,
  12     but a minimum of one a week, 50 a year, I would regard
  13     as a basic minimum.
  14   Q. A basic minimum for maintaining competence, knowledge
  15     and experience within that area?
  16   A. Yes.
  17   Q. Provided that sort of level of involvement was
  18     maintained, would you have any concerns about
  19     involvement in both adult and paediatric anaesthesia, in
  20     a unit which dealt with both types of cases?
  21   A. Not really, as long as they were basically competent to
  22     begin with and this level of competence was maintained.
  23   Q. Is that an answer that relates solely to a cardiac
  24     paediatric --
  25   A. It might also involve something like neurosurgical

   1     procedures, long procedures. If they are short
   2     procedures you can do a lot more in the time available.
   3     The total numbers are small anyway, so they are all
   4     rather limited. One's experience is limited by the
   5     extent of the surgery, really, and the time of the
   6     surgery, the length of time.
   7   Q. This report, the Working Party report, recommended, at
   8     page 18 of the report, when speaking of regional
   9     specialist surgical units, it noted the need to attend
  10     these regional specialist services on occasion, and they
  11     mentioned that there was the need for the designated
  12     surgeon and anaesthetist responsible for the services
  13     for children and the services provided should meet the
  14     criteria laid down in the Department of Health document
  15     for the Welfare of Children in Hospital.
  16        If we could just turn, please, to that report, it
  17     is at HOME 2/1.
  18        That is the title page. If we could go on to
  19     page 4, that is a general statement of the aims,
  20     including the statement -- this is towards the bottom of
  21     the first paragraph:
  22        "Children should not be admitted to adult wards as
  23     they are not only more emotionally vulnerable than
  24     adults, but also have different needs requiring
  25     alternative equipment, techniques and staff skills."

   1        Would you like to comment on that as an aspiration
   2     for the management of children?
   3   A. I totally agree with it, and I am sure all our members
   4     would do the same. It does not apply just to ward
   5     management but also to the operative procedures in the
   6     theatre; and recovery. One does not wish to mix up
   7     children with adults. This obviously applies across the
   8     board to all sorts of conditions and subspecialities of
   9     paediatric surgery and anaesthesia. Certainly, we would
  10     not recommend admitting children to an adult ward.
  11   Q. For how long has that been the consensus of opinion
  12     amongst the members of the Association?
  13   A. For pretty well ever, really.
  14   Q. So what sort of things get in the way of achieving that
  15     particular end?
  16   A. I think surgeons, generally, and those treating children
  17     and adults do not want the children moved to another
  18     site. That is a generalisation. Things are often
  19     historical. One starts with the unit that is basically
  20     an adult one, and then children have been taken on
  21     board, as it were, and the whole thing has blown up, and
  22     it becomes very difficult to dismantle a mixed unit.
  23     You actually have to put the children into another
  24     hospital, or into another children's hospital. It is
  25     actually very expensive to move -- setting up, the

   1     capital needs are high, the infrastructure, the actual
   2     staff costs of moving a unit, and everybody looks twice
   3     at the cost these days.
   4   Q. When you say that a surgeon might get in the way of such
   5     a move, is that a comment on the organisation of
   6     hospitals to reflect surgical specialities, or is that
   7     a comment on personalities?
   8   A. A bit of both, really. I think that when people do
   9     children and adults, the children often come out second
  10     best, I think. They are often smaller in number,
  11     anyway. It is often thought that, "Well, we will put
  12     the children with the adults because then it means our
  13     waiting lists, our operating lists can go more
  14     smoothly". It means our junior staff can look after
  15     both sets of patients on one site; it means that life is
  16     a bit easier, really. When people are very busy, that
  17     is often a factor.
  18   Q. That may be a factor which leads to the needs of
  19     children coming second rather than first; is that
  20     correct?
  21   A. Yes.
  22   Q. If we could move on to page 13 of the document, please,
  23     that has the ideals of a comprehensive children's
  24     department set out, if we can scroll up the
  25     page a little, please. I take it from the evidence you

   1     have given so far that that is a series of aims or
   2     desires that the Association would endorse?
   3   A. Yes.
   4   Q. If we could look on, however, please, to page 21, this
   5     is the paediatric intensive care service, where more
   6     specifically this particular type of ward is
   7     considered. There it mentions the BPA report, the
   8     previous Working Party report, that admitted should
   9     ideally be in a situation in which the child was cared
  10     for in a suitable environment separate from adults.
  11     However, whether the service was to be provided in
  12     a discrete children's unit or within a designated area
  13     within the ICU, there was a series of standards to be
  14     set out in terms of the staffing and services available.
  15        That Department of Health document therefore
  16     envisages that children may be cared for within
  17     a designated area within an adult ICU. Is that
  18     something the Association would have agreed with as an
  19     acceptable standard of care?
  20   A. It would not be the ideal. I think it was a pragmatic
  21     approach in that if you are going to have children in
  22     the district general hospital in an intensive care
  23     setting, you would rather have them in the intensive
  24     care setting than in the corner of the ward. That is
  25     disastrous for children. They should actually be in an

   1     intensive care unit, preferably their own, but failing
   2     that, a dedicated area of adult intensive care. I think
   3     this is what you might call an interim standard, if you
   4     like, because things have moved on since this particular
   5     report.
   6        I think this was making the best of a rather
   7     difficult and bad situation.
   8   Q. Does it follow from that that in fact it was fairly
   9     common, at that time, for children to be admitted to
  10     a part of an adult ICU ward?
  11   A. Yes.
  12   Q. And that now has changed?
  13   A. I think that it has been changing gradually, anyway, as
  14     big paediatric tertiary referral centres, mainly at
  15     children's hospitals, have actually expanded their
  16     intensive care unit and, indeed, provided retrieval
  17     teams so they can actually go to a DGH, or wherever, to
  18     actually pick up these children and transfer them back.
  19        So that, I think, has changed quite a bit, but
  20     certainly, the last intensive care report, the Troupe
  21     report, I think it was two years ago, I cannot think if
  22     it was last year or the year before it reported,
  23     suggested that there should be a need for a tertiary
  24     centre in every region and retrieval teams set out and
  25     this is where children requiring intensive care should

   1     go.
   2   Q. If you were asked to choose between models of care which
   3     have on the one hand involved a paediatric unit,
   4     including a paediatric intensive care unit, caring for
   5     children with a wide range of difficulties, problems,
   6     needs for surgery, and one which was based upon
   7     a designated surgical speciality with an ICU that
   8     therefore catered for both adults and children, how
   9     would you see the balance of advantage between those two
  10     models?
  11   A. I think that cardiac children have much, much more in
  12     common with other ill children, rather than having
  13     something in common with adult cardiac patients. They
  14     are very, very different. Children with cardiac disease
  15     have congenital cardiac disease; adults tend to have
  16     acquired cardiac disease. There is often a spectrum of
  17     age. There is not a lot of commonality between them,
  18     whereas the critically ill child in an intensive care
  19     unit, be they medically or surgery critically ill, has
  20     a lot in common with the critically ill cardiac child,
  21     so I would recommend that critically ill children,
  22     whatever is wrong with them, are nursed together in
  23     a paediatric intensive care unit.
  24   Q. Is this something that has achieved broader recognition
  25     over the years, or is that something that would have

   1     been as common a view of members of the Association back
   2     in 1973 as it may be now?
   3   A. I think that perhaps in 1973 intensive care, be it adult
   4     or children, was not so prominent as it is now, but even
   5     so, I think there was an awareness that if you were
   6     going to deal with children, they should be in their own
   7     home, as it were, a specialty area, and you should not
   8     mix them up with adults.
   9        I think that certainly over the years this has
  10     become much, much more apparent.
  11   Q. If you do have to mix them with adults because you have
  12     not been able to move away from the ICU which is based
  13     upon the surgical specialty, what compensating factors
  14     do you have to bring into play to ensure that children
  15     do not receive an inadequate or second class standard of
  16     service?
  17   A. I think firstly you should segregate them from the
  18     adults. They should have their own sub-unit within the
  19     intensive care. I think they should have paediatrically
  20     trained nurses, paediatrically trained intensive care
  21     nurses, or at least, if they are general nurses, they
  22     should have spent some time in a paediatric unit to know
  23     what it was all about.
  24        I think that they should have the medical care
  25     post-operatively of people who constantly deal with

   1     children, be they paediatricians -- well, nowadays we
   2     call everybody an "intensivist", but they can be either
   3     paediatricians or anaesthetists, but I do believe that
   4     those people should have considerable experience of
   5     dealing with just children in general, never mind
   6     cardiac children.
   7   Q. If we could go on then to the further document which
   8     again looked at the question of a management of
   9     children's care in anaesthetic services. This is
  10     Children's Surgical Service, a report of the Royal
  11     College of Paediatrics and Child Health, as it had then
  12     become, December 1996. This is at APA 1/1, which
  13     I think will give us the title page. If we turn,
  14     please, to page 3, this is a report which again the
  15     Association of Paediatric Anaesthetists was represented
  16     on. It is Dr John Wandless who sat on this particular
  17     Working Group.
  18        At page 5 it sets out the aims of this particular
  19     group, where we are told that -- we are given the
  20     history of the CEPOD report, and then, at paragraph 1.3,
  21     the document we have already looked at, February 1993,
  22     the transfer of infants and children for surgery.
  23        Then, if we could look, please, at paragraph 1.4,
  24     the difficulties in implementing that particular report
  25     are there set out. Therefore the BPA has convened an

   1     ad hoc Multidisciplinary Children's Surgical Liaison
   2     Group to consider that Working Party report and other
   3     relevant reports.
   4        If we could look, please, at page 6, there is
   5     there set out a summary of the agreements reached in
   6     this particular field on the nature and type of skilled
   7     staff that were required, and in particular, there is
   8     the aspiration set out at the top that children should
   9     not be admitted to adult wards generally.
  10        If we look at paragraph 2.2.2, there is the
  11     recommendation, the summary of the agreement, on
  12     paediatric anaesthetics in particular, where, again, we
  13     see the recommendation that there should be nominated
  14     consultant anaesthetists suitably trained in paediatric
  15     cardiac anaesthesia, responsible for services for
  16     children.
  17        There you have spoken already of consultants who
  18     need to operate on at least one child a week, or one
  19     operating list per week, perhaps, if the procedures are
  20     shorter -- might take up a shorter length of time.
  21        Can I just ask you: this is a standard, a very
  22     specific standard, about the level of paediatric
  23     anaesthetic experience, and it is set out now in 1996.
  24        Do you think that that level of experience was
  25     something that would have been recognised and understood

   1     by paediatric anaesthetists, or anaesthetists more
   2     generally, at an earlier point during our terms of
   3     reference, say back in 1984/85?
   4   A. I think that a lot of anaesthetists recognised their
   5     limitations and actually would have preferred not to
   6     undertake anaesthetising small children. I think above
   7     the age of 5, it is not really a big problem, but below
   8     5, and below 2, in particular, it is a problem. I think
   9     a lot of them recognised their limitations, were not
  10     happy doing it, but, because of the nature of the
  11     organisation they worked in, they felt obliged to do
  12     it.
  13        I think a lot of them felt that if they could have
  14     a reason not to do this, they would be delighted.
  15   Q. If an institution were carrying out no more than, say,
  16     13/14/15 operations per annum in the field of paediatric
  17     cardiac anaesthesia upon infants, would that be a level
  18     of operation that would be sufficient to maintain
  19     competence and skill in the area?
  20   A. Did you say 14?
  21   Q. 13/14/15, that sort of figure per annum.
  22   A. No, because I do not believe it was the same
  23     anaesthetist each time doing those, and even if it was,
  24     it is a very small number.
  25   Q. When you say 'infants', do you mean under a year?

   1   A. I do, yes. I think it is borderline. They might have
   2     been doing sort of another 650 who were 13 months old
   3     and that would not have been so bad, but I think just
   4     taken as a bald figure, it is a small number.
   5   Q. Are there any ways of increasing your experience in
   6     relevant related procedures? You have mentioned that
   7     one compensating mechanism might be, for instance, to do
   8     operations on children who are 13 or 14. What about
   9     operations to anaesthetise for operations in non-cardiac
  10     fields? Would that be a way of compensating?
  11   A. I think it probably is. As I think I said a little
  12     while ago, there is a lot in common -- children with
  13     congenital heart disease have similarities to other
  14     children of the same age, with other major illnesses,
  15     and I think that people who anaesthetise children every
  16     day, every week, probably find things much easier than
  17     somebody who is just one day a week doing the odd child.
  18   Q. If we turn to page 9 of this document, we see there the
  19     recommendations, or the position statement, that was
  20     specifically submitted by the Association of Paediatric
  21     Anaesthetists which really reflects what you have been
  22     telling the Panel in the nature of the experience
  23     required by a consultant paediatric anaesthetist to
  24     undertake this form of work.
  25        The statement says that new-born infants should

   1     only be operated on by an anaesthetist and surgeon
   2     experienced in the care of neonates.
   3        Again, are you able to help us as to the meaning
   4     of the word "experienced" in that document?
   5   A. I think, again, experience is to do with numbers and how
   6     often one is dealing with these new-born babies.
   7     I think "new-born infants" here refers mainly to the
   8     general paediatric surgery. I think you showed a bit
   9     earlier, not in the document but the previous one,
  10     a list of the kind of conditions and they were mainly
  11     paediatric surgery, but as I say, I think the key to all
  12     this is the numbers that people do and how often they
  13     anaesthetise children. This is, I think, just
  14     a new-born infant --
  15   Q. We have touched, therefore, upon the question of the
  16     specific need for paediatric anaesthesia experience for
  17     procedures. Can you help us a little on the mechanics
  18     by which that sort of experience would be gained by
  19     someone hoping to practice as a consultant paediatric
  20     anaesthetist?
  21        Firstly, let us start by talking about the period
  22     from 1984 to around 1995, 1984 to 1994/1995, prior, in
  23     other words, to the implementation of the reforms
  24     suggested by the Calman report.
  25        It would be right firstly that the first stage of

   1     training would be a general professional training, or
   2     basic specialist training, leading eventually to
   3     membership, fellowship, of the Royal College of
   4     Anaesthetists.
   5        What would be the level of exposure to paediatric
   6     anaesthesia that would be achieved during that stage of
   7     professional training?
   8   A. I think it would be fairly limited, and fairly general.
   9     The majority of people doing general professional
  10     training, as it was then, and which are now SpRs 1 and
  11     2, then were mostly based in DGHs or university
  12     hospitals. They are based around a school of
  13     anaesthesia now, but in fact it was ever thus; it was
  14     not much different, really.
  15        So they tend to have a more general training for
  16     the first couple of years. Their exposure to children
  17     will be on very much an ad hoc basis, doing children for
  18     tonsils, squints, orthopaedic procedures, a bit of
  19     general surgery, as they come up in a DGH. A lot of
  20     children are anaesthetised and operated on perfectly
  21     adequately in DGHs having small routine procedures,
  22     often as a day case. There is no argument with this.
  23     Those are where the juniors in the early years of their
  24     training, the trainees would be exposed to that sort of
  25     patient.

   1        Then afterwards, when they have their fellowship
   2     and they move on to what was a Senior Registrar and is
   3     now an SpR 3, 4, soon to be 5, that is where they will
   4     be exposed to more of the subspecialties of anaesthesia
   5     and can usually spend about six months, probably not
   6     more than that, doing something in-depth.
   7        So, for example, at the moment we have three SpR 1
   8     and 2s, trainees, at our hospital, which are doing very
   9     general stuff, really, and then we have about another
  10     8 who are more senior, who are doing 6 months. All of
  11     these people, unfortunately -- I say "unfortunately";
  12     I ought to qualify that -- are on rotation. They are
  13     all part of the school of anaesthesia, as is everyone
  14     else in this country, where rotation is necessary and
  15     mandatory, and everyone rotates through various
  16     hospitals and various subspecialties.
  17        People who wish to make a career in full-time
  18     paediatric anaesthesia must have at least 12 months of
  19     paediatric anaesthetic experience before they can even
  20     think about applying for a job, and in many instances,
  21     that means actually doing sort of maybe 9 months in this
  22     country, and indeed, something like 6 months to a year,
  23     often, abroad at another major children's hospital.
  24   Q. What particular children's hospitals would be regarded
  25     as being centres of excellence, or good training abroad?

   1   A. Australia, Melbourne Children's hospital, Boston
   2     Children's Hospital, Toronto, and there are others that
   3     people have been to, but they are usually very large
   4     tertiary referral centres.
   5   Q. What advantages would training in those centres offer to
   6     someone who was interested in paediatric anaesthesia?
   7   A. It offers, obviously, perhaps a different perspective,
   8     and it is added experience. If we had a system in this
   9     country, which I hope we may soon, whereby we were able
  10     to offer interested individuals a sort of two-year
  11     training period in paediatric anaesthesia, rather than
  12     endless rotations, if we were able to do that I think
  13     that people would not necessarily go abroad; they might
  14     rotate between two or three of the major paediatric
  15     hospitals in this country, rather than going abroad. At
  16     the moment it is a sort of necessity.
  17   Q. You are expressing the view that it is the length of the
  18     exposure to that particular specialism which can be
  19     increased by going abroad, rather than that there is
  20     a different level of training or expertise which is on
  21     offer at those centres?
  22   A. That is right, although it is always useful to go to
  23     more than one centre. You do gain by seeing perhaps an
  24     alternative practice, a slightly different practice,
  25     slightly different mix of patients.

   1   Q. So can you summarise the level of exposures to
   2     paediatric anaesthesia that a candidate would have once
   3     they reached the end of specialised training and were
   4     applying for a first post as a paediatric anaesthetist?
   5   A. If they were applying for a full-time post in paediatric
   6     anaesthesia, which would probably be a children's
   7     hospital or a big university hospital, then they would
   8     have to have had at least one year of intensive
   9     paediatric anaesthesia within a specialised unit, and be
  10     exposed to all that, all the various subspecialties of
  11     paediatric anaesthesia, like neuro, plastic surgery, all
  12     sorts.
  13        If they were going to apply for a job in a DGH or
  14     maybe a university hospital with an interest in
  15     paediatric anaesthesia, that is, half adult practice,
  16     half paediatric practice, they would have to demonstrate
  17     that they had at least 6 months of intensive paediatric
  18     training at a specialist unit.
  19   Q. Where does paediatric anaesthesia within the context of
  20     a cardiac surgery ward fit into those two categories?
  21   A. Somebody for that, I think, would need training in
  22     paediatric anaesthesia, or certainly, paediatric cardiac
  23     anaesthesia, and, indeed, in adult anaesthesia, if they
  24     are going to do -- are you talking about in a mixed
  25     unit.

   1   Q. I am, yes, I am sorry.
   2   A. They would need, obviously, a considerable amount of
   3     cardiac anaesthetic experience, and additionally, they
   4     would need to have seen a considerable amount of
   5     paediatric cardiac anaesthesia.
   6   Q. How good do you think the system that you have just
   7     described was at supervising trainees during this
   8     three-year period of movement from fellowship towards
   9     a first consultant's post?
  10   A. I think it was, in anaesthesia, pretty good. There have
  11     been college tutors for a long time. In every hospital
  12     there is someone who looks after the trainees. The
  13     trainees have always filled in logbooks and have done
  14     for many, many years, often computerised logbooks,
  15     et cetera, so these were looked at so people could
  16     actually see what they had done.
  17   Q. Was that then a system that was adequately designed to
  18     measure practical competence as a job as well as
  19     theoretical knowledge and exposure to different types of
  20     procedures?
  21   A. Anaesthesia, above all else is a practical subject.
  22     Obviously there is a lot of theory as well, but you have
  23     to be good at the practice. It becomes very clear,
  24     early on, if somebody is not good at the practice and
  25     then they are just quietly removed into another

   1     specialty, or they should be.
   2   Q. Or they should be?
   3   A. They usually are.
   4   Q. Culmination of this training is obviously an application
   5     for a consultant anaesthetist's job, perhaps
   6     a consultant paediatric anaesthetist. During the 1980s
   7     and 1990s, what was the level of availability for
   8     candidates for such posts? Were there usually more than
   9     adequate applications, or were there shortages?
  10   A. For full-time paediatric anaesthetists, usually a small
  11     field. It rather varied from year to year. There were
  12     never that many posts, not huge numbers compared with
  13     the adult work, but always, usually, adequate numbers
  14     and invariably somebody appointable actually applying.
  15   Q. Was there no problem, then, with the numbers of
  16     candidates offering for a particular job that might, for
  17     instance, have led to doctors being promoted to
  18     consultant after only, say, 18 months as an SRO, rather
  19     than having longer experience before such an
  20     appointment?
  21   A. I have no particular experience -- I have no experience
  22     of that. I am not aware of it, although I am certain it
  23     probably does happen. It is not something that one
  24     would recommend, or, indeed -- well, I do not think it
  25     is appropriate, really.

   1   Q. I have asked you to describe the training model prior to
   2     the implementation of the Calman report. Could you
   3     describe briefly the impact of that from the point of
   4     view of the Association of Paediatric Anaesthetists?
   5   A. What, the introduction of Calman?
   6   Q. Yes, the changes that has made to the training patterns
   7     for paediatric anaesthetists.
   8   A. At the moment, it has not really made a great deal of
   9     difference. What it has suggested is that everyone
  10     should of course be exposed to paediatric anaesthesia,
  11     so that in some areas, I believe, they are getting quite
  12     a lot of very junior people rotating round the system at
  13     an earlier stage, which actually is causing problems.
  14     There may be one or two isolated areas, I am not sure it
  15     is terribly relevant to this Inquiry, but I think that
  16     one of the dangers of having everybody doing a bit of
  17     everything is that nobody gets good at anything.
  18     I think this will get sorted out. I think the extra
  19     year that the Royal College of Anaesthetists is planning
  20     now in training, it always used to be 5 years, it went
  21     down to 4 and now is back to 5, I think that will make
  22     a difference. It allows more time for people to do more
  23     in-depth training.
  24   MISS GREY: I have been asking you questions for about an
  25     hour and a quarter. I think this may be an appropriate

   1     moment for a break. I have another 20 minutes at the
   2     top end, so I am in your hands and that of the
   3     Chairman.
   4   THE CHAIRMAN: Thank you, Miss Grey. We will take
   5     a break for 15 minutes, and then reconvene at noon.
   6   (11.45 am)
   7               (A short break)
   8   (12 noon)
   9   MISS GREY: Before the break, Dr Jones, I had been asking
  10     you about your opinion on the Calman changes. You had
  11     been in effect underlining the point you had been making
  12     about the need for practical training by expressing at
  13     least some reservations about the extent to which the
  14     trainees could be exposed to that form of practical
  15     training under the new Calman regime.
  16        Is that a fair summary?
  17   A. Under the present Calman regime, but I believe, as
  18     I say, there is going to be added an extra year which in
  19     effect is going to allow more people to pursue one of
  20     the subspecialties in more depth. That certainly will
  21     have an effect.
  22   Q. If we could move to the issue of continuing professional
  23     education after appointment as a paediatric
  24     anaesthetist, what would have been the mechanics for
  25     such continuing development during the years from 1984

   1     to about 1995?
   2   A. As I say, there are conferences one can go to,
   3     consultant update days, refresher courses, and indeed,
   4     a lot of people, often in highly specialised fields,
   5     will actually take a month or a couple of months to
   6     actually go and visit other centres and indeed, they
   7     have always done this -- not with any regularity and not
   8     everybody does this, but going to see what other people
   9     are doing in your own field and in another institution
  10     is often a way of updating yourself.
  11   Q. How often do busy professionals have the luxury or
  12     support from their own institution to take a month or so
  13     out of their practice to go and do that?
  14   A. I think you have to make a very good case out for doing
  15     this. It may be that you cannot actually take all that
  16     time off in one go; you may have to go for a week and
  17     then another week the next month, this sort of thing.
  18     I do not think many people will be prepared to do it
  19     entirely in their own time.
  20   Q. In the academic world by comparison, a one-year
  21     Sabbatical every 7 years or so is a recognised
  22     professional entitlement. How does the medical
  23     profession compare to that in terms of the frequency
  24     with which a professional might be able to obtain time
  25     off to study other institutions?

   1   A. Very badly indeed. I think that there is just not
   2     enough slack in the system to allow people time off to
   3     go to other institutions, not if you have a small
   4     department, say. It would be very difficult. Indeed,
   5     it would be a great strain on one's colleagues left
   6     behind. I think in the bigger institutions with more
   7     people it may be one can make out a better case for
   8     being away for perhaps longer, but it is not easy.
   9   Q. Is there any formal place or recognition in the
  10     consultant's contract for time needed to maintain
  11     professional competence, or keep up to date with
  12     scientific publications?
  13   A. No, not on a formal job plan. There is always the usual
  14     line, you know, "must take part in audit, departmental
  15     audit" and this that and the other, but actually no time
  16     is allowed for that.
  17   Q. You have mentioned the work of Associations in effect
  18     such as that of the APA in publishing, in promoting
  19     scientific meetings, conferences. You have mentioned
  20     the role of discussion with colleagues, whether it is
  21     within an institution or by visiting other institutions,
  22     or by meeting colleagues at conferences.
  23        What about the question of training of junior
  24     doctors? Does that have a role in promoting continued
  25     professional development for consultants themselves?

   1   A. I think if you are actually training people to
   2     effectively replace you, then there should be probably
   3     a structured format for doing that in terms of lectures,
   4     tutorials, making sure they get exposed to the various
   5     aspects of paediatric anaesthesia, and also, I think it
   6     sharpens up your own mind in that you have to teach
   7     people, and you have to teach them properly. You are
   8     teaching the next generation.
   9   Q. You say that there ought to be a structured format for
  10     putting in place the training requirements upon
  11     a consultant, so that they in turn can teach others.
  12     What institutions or mechanics did in fact exist to
  13     impose upon those who were in a teaching position those
  14     sorts of requirements?
  15   A. I suppose the Royal College of Anaesthetists has, for
  16     many years -- I have no in-depth knowledge of this, I am
  17     not a college tutor, but certainly the college tutor in
  18     our hospital for many years has been organising the
  19     programme of training for our trainees, and I assume
  20     that much the same happens or has happened in other
  21     institutions, and indeed should happen throughout the
  22     country.
  23   Q. If you are a college tutor. Does it follow you are not
  24     best placed to comment on the efficacy of the mechanics?
  25   A. No, I do not think I am, probably, in the academic

   1     sense.
   2   Q. I will leave that if I may and pass on to the question
   3     of audit. What professional obligation is placed upon
   4     an anaesthetist to take part in an audit across the
   5     years from 1984 to 1995?
   6   A. Probably none in 1984. Audit, really -- a lot of people
   7     have always audited what they do, often on
   8     a departmental basis. A lot of people have kept their
   9     own records of every single case they have ever done.
  10     I presume this is a learning experience, but audit only
  11     really came into being about 1990/91/92, that sort of
  12     time, where it became the last Health Service reform.
  13     Audit suddenly became a big word. I think that the
  14     medical staff thought this was a good thing, and indeed,
  15     I think had views on how they wished to look at audits.
  16     The trouble was, I think in a lot of hospitals, "audit"
  17     meant rather different things to the management of the
  18     hospital than it did to the medical staff.
  19   Q. Can you explain what firstly the medical staff
  20     understood by the term?
  21   A. I have always understood, and I think most of my
  22     colleagues did, that you are auditing what you do, in
  23     that you set a standard, you see how far away you are,
  24     or how close you come to that standard of practice, and
  25     you take steps to alter it, and then you reaudit what

   1     you are doing to see how you have advanced, what you
   2     have learned and how you have progressed. I think that
   3     the majority of people, doctors -- well, the clinical
   4     staff of the hospital, thought this was the way to
   5     progress. Unfortunately, I think that sometimes the
   6     management do not quite see it that way. I think this,
   7     again, is a financial thing, that in fact it ended up
   8     with people looking at numbers, head counts, league
   9     tables and things like that. It all got rather moved
  10     sideways, really.
  11   Q. What sort of numbers do you mean in those head counts?
  12   A. Only in the sense of numbers of patients treated,
  13     numbers of patients put through beds, whether this is
  14     efficiency, really.
  15   Q. What you are talking about there is activity indicators,
  16     efficiency indicators?
  17   A. It is.
  18   Q. Are you saying that the medical profession had a greater
  19     idea of auditing or evaluating quality or outcomes than
  20     was always the case at the managerial level?
  21   A. The simple answer to that is probably yes. They would
  22     prefer to see, as you say, the quality of what they were
  23     doing. Those who were interested in audit, I have to
  24     say, not everybody was, but I think that people would
  25     like to know how they are doing, as it were, even within

   1     their own institution.
   2   Q. When audit was first introduced, it tended to get
   3     introduced under the heading of "medical audit"?
   4   A. Yes.
   5   Q. Perhaps two years later there was a move towards using
   6     the term "clinical audit"; a Government-led change,
   7     perhaps?
   8   A. Yes.
   9   Q. What did that difference in terminology mean to
  10     anaesthetists, if anything?
  11   A. It probably did not mean very much to anaesthetists, but
  12     the medical profession, overall, it moved audit from
  13     just being a medical matter into the whole of the
  14     clinical field within the hospital, which is no bad
  15     thing, but, if you like, it then got diluted, the kind
  16     of audit you could do, because it had to include so many
  17     other groups, nursing, paramedical, this sort of thing.
  18        So if you were looking, say -- we, for example, in
  19     my department, even before audit became a buzz word, we
  20     always had our audit forms to fill in for every
  21     anaesthetic, which just goes through the page reader,
  22     and we had those for a very long time, and continued to
  23     do that. If we wished to actually sit down and spend an
  24     hour or two during the working week, all of us sit down
  25     together to discuss, say, just for an example, how many

   1     children are vomiting after their anaesthetic, it
   2     becomes practically impossible to get everybody to sit
   3     down in one place and actually have the time or whatever
   4     to collect these statistics.
   5   Q. When you say "everyone" in that example --
   6   A. All the consultants, all the junior staff.
   7   Q. Within the anaesthetic department?
   8   A. Yes. I mean stopping all the operating.
   9   Q. So there is a practical problem in timetabling space to
  10     gather the anaesthetic department together.
  11        When medical audit began, or was formalised,
  12     perhaps I should say, was this an activity that was seen
  13     as involving the anaesthetic department on its own, at
  14     first?
  15   A. No. I think that everyone needs to audit their own
  16     departmental work, but obviously, you do not give
  17     anaesthetics in isolation. We would wish, I would have
  18     thought, to discuss audit along with the surgeons, of
  19     all kinds.
  20   Q. You would wish?
  21   A. Yes.
  22   Q. Is that an aspiration, or a practical reality?
  23   A. A bit of both. Surgeons again often like to discuss
  24     their own, and again there is not often time for --
  25     there are some instances where one has a sort of joint

   1     lunchtime meeting, but again, not everyone can always
   2     attend this. But I think that if one is going to do
   3     audit properly, in its widest sense -- the most
   4     important sense -- then one actually needs time to do
   5     this.
   6   Q. Did the shift in terminology from medical audit to
   7     clinical audit make any difference in the practicalities
   8     of achieving liaison between different departments,
   9     different specialities, to discuss common problems,
  10     themes?
  11   A. I do not think it did in my particular hospital, but
  12     I can see that it could do, I think because it widened
  13     it from medical audit, which perhaps involved 20 people,
  14     to clinical audit which might involve 40 people, on
  15     a particular topic, then in fact it became much more
  16     difficult to get everyone together under those
  17     circumstances.
  18   Q. That is to have touched upon a variety of different
  19     means of continuing professional evaluation or
  20     education. Can I ask you the general question: how
  21     effective do you think all those mechanisms were during
  22     the period, again, up to about 1995, in encouraging or
  23     fostering good standards and practices?
  24   A. I think it depends very much on the institution and the
  25     individuals within it, how they work together, how they

   1     see their relative roles, how seriously they did take
   2     audit. I think that where everybody was of a like mind
   3     and there was time and the inclination for people to get
   4     together to discuss problems, then I think it probably
   5     worked very well.
   6        If none of those factors -- if people did not wish
   7     to take part or did not have the time or inclination,
   8     then I think that audit would be doomed.
   9   Q. Is that something that you would apply more generally
  10     across not merely the field of audit, but other aspects
  11     or other forms of achieving continued professional
  12     education, keeping up to date with scientific
  13     literature, the attending of conferences and so on?
  14   A. We do actually have to fill in our little booklets to
  15     say what we have been to and what we have done: for
  16     continuing medical education you have to have so many
  17     points for internal and external, sort of, CMEs, and
  18     these are inspected.
  19   Q. That relates to what time-frame?
  20   A. Over the period of a year and in any three-year period.
  21   Q. Since when has that obligation been imposed?
  22   A. I suppose about the last three or four years.
  23   Q. Prior to that?
  24   A. Nothing of the time, no.
  25   Q. If we relate the answer back again to the period broadly

   1     from 1984 to 1995, what would you have seen as being the
   2     major obstacles to fostering a culture of continuing
   3     professional education and learning during that period?
   4   A. I think the individual's inclination. Everyone does get
   5     study leave. Just to go back to where you were asking
   6     about a visit to other institutions, one could use one's
   7     study leave to do that, but it is only 10 days in the
   8     year. By the time you have been to a couple of
   9     conferences, it does not leave you very much time to do
  10     anything very much in depth, but people have always had
  11     study leave available to them which they should, or can,
  12     use. I think it is very much an individual thing, as to
  13     how people have gone about self-education or continuing
  14     education.
  15   Q. You have now spoken in your witness statement on behalf
  16     of the Association of the fact that the Association is
  17     supportive of the concept of revalidation, and also, you
  18     have discussed briefly the concept of interdepartmental
  19     peer review as being the way forward for the future.
  20        What would the second concept comprise?
  21   A. This is something we have been discussing for at least
  22     a year now. It is all still in the theoretical stage at
  23     the moment. We were going to move ahead, but in fact
  24     decided we had better wait for the Royal College of
  25     Anaesthetists and the General Medical Council to give

   1     the go-ahead, as it were. The idea would be that as
   2     a first-off the bigger children's hospitals would,
   3     I would not say audit each other, but have produced
   4     a series of guidelines, protocols, whatever you like,
   5     that should be in place for an institution to aspire
   6     to. Then one would actually audit between the various
   7     hospitals, as it were, and in order to make this
   8     non-cosy, as it were, one would have external people on
   9     this, including, perhaps, a lay member of the public.
  10        But this, as I say, is all very much in theory at
  11     the moment. We are waiting for the Royal College of
  12     Anaesthetists to actually lay down where they see peer
  13     review and audit going in this respect.
  14   Q. So what pressures or concerns has that discussion been
  15     a response to? What was the trigger for it?
  16   A. I think the GMC getting very active over the last two
  17     years and the concept of revalidation. Once continuing
  18     education, CME, came in, there was no doubt that things
  19     were going to move forward from there, and that one
  20     would have to go along a line of something like
  21     revalidation in some form or another.
  22   Q. If I could just take you back, please, to the more
  23     practical reality or the detailed point of the
  24     involvement of the anaesthetist in surgery for children,
  25     if I could take you back firstly to the pre-operative

   1     stage, or prior to surgery, if we could discuss the role
   2     of the anaesthetist in that sequence of events, if we
   3     could have up the CPOD file 1/123, this is just by way
   4     of comparison. If you scroll through to the bottom of
   5     that page, there is just the one line there:
   6        "81 per cent of children amongst index cases in
   7     district general hospitals and 85 per cent in university
   8     hospitals were visited by the anaesthetist before
   9     surgery."
  10        Can you comment on what would be standard or good
  11     practice amongst anaesthetists for that stage of
  12     procedures?
  13   A. It should read "100 per cent". There are times where it
  14     is practically impossible to go and see the patient. If
  15     you are single-handed in the theatre and the patient
  16     comes in after the list has started, it may be that you
  17     do not get an opportunity to go to the ward, or it may
  18     be such a dire emergency that the child comes straight
  19     in from the Casualty Department or something like that.
  20     But certainly for elective cases, all the children
  21     should be seen by anaesthetists and preferably the one
  22     that is actually going to anaesthetise.
  23   Q. Why is that important, at the risk of underlining the
  24     obvious?
  25   A. I think certainly in children you need to introduce

   1     yourself to the child and parents; they need an
   2     explanation of what you are and what you are going to
   3     do; you need a discussion, not an in-depth discussion,
   4     about the anaesthetic, but they certainly need to know
   5     about pain relief afterwards.
   6        You need also to know about the general condition
   7     of the child. You need to know, do they have a history
   8     of previous anaesthetics, do you need to know whether
   9     they have anything other wrong with them, whether they
  10     have had reactions to anaesthetics, whether there is
  11     a family history of reactions to anaesthetics. There is
  12     a lot of stuff you need to know beforehand which you can
  13     only know if you visit them. You can spend 10 minutes
  14     in the anaesthetic room going through all this, but this
  15     is inappropriate, really.
  16   Q. What about the interaction with the child and his or her
  17     parents, assuming they are not old enough to comprehend
  18     the surgical procedures themselves? Should the
  19     anaesthetist be discussing the nature of the risks
  20     attaching to surgery?
  21   A. I think that the risks of surgery should be expounded by
  22     the surgeon. The risks of anaesthesia in that
  23     particular instance should be expounded by the
  24     anaesthetist. They are not necessarily the same thing
  25     at all. Occasionally, if the patient asks, in

   1     a particularly difficult situation I will also go into
   2     the risks of surgery, to the best of my ability, if only
   3     to reinforce what has already been said.
   4   Q. But there is a separate role for the anaesthetist to
   5     explain the risks of the anaesthesia before the surgery
   6     takes place?
   7   A. Yes.
   8   Q. How would you fit that into the question of obtaining
   9     consent for surgery?
  10   A. The consent for surgery is taken by the surgeons, and
  11     invariably, alongside, certainly in children, under
  12     general anaesthesia. We do not take at the moment
  13     separate consent for anaesthesia. However, I think
  14     where there is a real risk of death or damage or
  15     complications, then I always write that down, in that
  16     I have indicated to the parents that there is an
  17     additional risk, maybe, and that I have discussed this
  18     with the parents.
  19   Q. For how long have you been adopting that practice?
  20   A. I have done it for quite a long time. I may write it in
  21     the notes, I usually do write it in the notes, but
  22     sometimes just on the anaesthetic form itself.
  23   Q. "Quite a long time" could be --
  24   A. Well, several years.
  25   Q. So what, early 1990s, late 1980s? Can you help us?

   1   A. Probably early 1990s, I think.
   2   Q. So a consultant anaesthetist should have met the child,
   3     had a discussion with his or her parents about the risk
   4     of surgery. What about a discussion with the surgeon
   5     himself or herself? What would you expect to take place
   6     on that front before surgery?
   7   A. I think it depends entirely on the nature of the
   8     operation. A lot of what one does is elective
   9     anaesthesia which one has done before with a surgeon one
  10     has worked with before, and a lot of it is fairly
  11     routine, or the risks are common to all patients, as it
  12     were, in that particular category, and one knows about
  13     them.
  14        I think if there is something different, then the
  15     surgeon should perhaps indicate to the anaesthetist that
  16     there is a specific risk attached here, and I think that
  17     that requires discussion between the two of them,
  18     especially if there is any question of doing or not
  19     doing the operation.
  20   Q. If I could take you, please, to page 116 of CPOD, that
  21     is first of all a table saying, as a heading:
  22        "Anaesthetist consulted by surgeon before
  23     operation."
  24        If we look at the cardiac column, there are some
  25     95 cases in which that took place and some 5 per cent in

   1     which that did not take place. That is about 45 per
   2     cent of cases, according to my rough calculation.
   3        Then, if we could flick back a page, just to put
   4     a context to that table, page 115, if I could just
   5     invite you to read the bottom paragraph of that page,
   6     where the absence of consultation is discussed by the
   7     authors of the report. Do indicate when the page needs
   8     to be turned.
   9        The authors of the report there are expressing at
  10     least some surprise that the practice of consultation
  11     between anaesthetist and surgeon was not rather more
  12     widespread. Is that a comment that you would endorse,
  13     or agree with?
  14   A. I think I would have to know the nature of the
  15     operation, and indeed, the degree of risk, the degree of
  16     emergency. But I think -- I am not exactly sure what
  17     they mean about consultation, i.e. face-to-face
  18     discussion about it or a telephone call, or in fact the
  19     anaesthetist at least knowing a bit about the child the
  20     day before, say.
  21        I do not expect to be consulted, even in cardiac
  22     surgery, by the consultant surgeon, if he does not
  23     believe, or if I do not believe, there is a particular
  24     problem with that child. I am going to find out, I am
  25     going to see the child and read the notes -- and I would

   1     have seen that the day before. So if there is something
   2     I am not happy about, I can then discuss it with him.
   3     But for routine, elective patients -- and I know it is
   4     hard perhaps to imagine that a child having a heart
   5     operation is routine, but some are, or a lot are,
   6     actually, but nevertheless, they are, and I would not
   7     expect to be consulted in depth.
   8        If it was an emergency, if there was a real risk,
   9     then I would expect the surgeon perhaps to say to me,
  10     "There is a problem with this child". But I would not
  11     expect an in-depth conversation.
  12        I think a lot of these -- I do not know -- some of
  13     those may well have been emergencies.
  14   Q. Does it follow from that that the onus of initiating
  15     a discussion lies upon the person who first has some
  16     sort of knowledge or concern that there may be something
  17     out of the ordinary, or something slightly more unusual
  18     about this case that might raise additional risks?
  19   A. I would have thought so.
  20   Q. So there is no particular magic in whether it is the
  21     anaesthetist or the surgeon; it is just whoever thinks
  22     there may be something?
  23   A. Usually the surgeon has made a decision to operate at
  24     a particular time on a particular day and presumably he
  25     or she would know if there were any risks. By and

   1     large, they are going to be the people who would pick up
   2     first, one would hope, if there was a major problem with
   3     the child and things were not quite so routine.
   4   Q. Just returning to the question of seeing the child
   5     before the operation, would it be standard practice for
   6     the anaesthetist who is actually going to carry out the
   7     anaesthetic to see the child, or would delegation to
   8     another member of staff be common or acceptable?
   9   A. I think that the people, the anaesthetist, or there may
  10     be two in major cases, should see the child themselves,
  11     one or other, or both, preferably, and I think that in
  12     a major case, with a real risk, it should be the
  13     consultant who sees the child. I do not think that
  14     delegating it to a trainee, for example, who may know
  15     nothing about cardiac surgery or whatever, is
  16     acceptable.
  17   Q. Cardiac surgery or whatever: are we talking about
  18     cardiac surgery here?
  19   A. Cardiac surgery or other major procedures, which I think
  20     are the areas of concern here. If you are going to see
  21     a child who is going to have his tonsils out, you can
  22     delegate the junior who is with you to go and see that
  23     child, but I would not have thought so for a heart
  24     operation or a neurosurgical operation or cancer
  25     surgery, or something like that.

   1   Q. As you said, we are talking about cardiac surgery or
   2     other major procedures. Does it also follow from what
   3     you have been saying you would expect a consultant
   4     anaesthetist to be in charge of anaesthetic during an
   5     operation?
   6   A. On a child, yes.
   7   Q. I think it is right, is it not, that CPOD found that
   8     standard was generally being attained throughout these
   9     forms of procedures?
  10   A. Yes.
  11   Q. If one moves to post-operative care, what aspect of that
  12     would the paediatric anaesthetist be responsible for?
  13   A. Again, it all depends on the set-up in the particular
  14     institution. Generally, if you are looking at cardiac
  15     anaesthesia, again, then if you are in the theatre, you
  16     cannot be in two places at once and you do need to
  17     delegate the care, or the respiratory care, I think, of
  18     the child to a competent person present in the intensive
  19     care. This can be difficult and used to be much more
  20     difficult, but I think over the last ten years there has
  21     been a realisation that intensive care is not just an
  22     add-on to surgery, it is an entity in its own right.
  23     People do recognise this, and they are there all the
  24     time.
  25   Q. Have you been describing the sorts of factors that led

   1     to the development of intensivists as a specialised
   2     profession?
   3   A. Yes, I think so. By and large, intensive care for
   4     whenever it started, really, some time in the 1950s,
   5     generally is run by either anaesthetists or sometimes
   6     respiratory physicians, certainly in adult hospitals,
   7     with input from other people when necessary. Still, in
   8     fact, in the majority, I think, of intensive care units,
   9     the anaesthetists are perhaps the most numerous doctors
  10     available within the intensive care unit and in a lot of
  11     places -- they may not do all intensive care, but maybe
  12     half your working week is involved in intensive care and
  13     the other half in anaesthesia.
  14        Gradually, I think with neonatology, which has
  15     been going now for a considerable number of years, since
  16     the late 1960s, really, neonatologists, who are
  17     paediatricians, are becoming more interested in the more
  18     acute aspects of medical practice, and in fact
  19     paediatricians are also becoming interested in intensive
  20     care as a career. So you now have intensivists who can
  21     be either anaesthetists or paediatricians, they diverge
  22     at the beginning and then follow a common pathway in
  23     training now to become a paediatric intensivist.
  24   Q. Focusing on the cardiac surgery unit and its related
  25     ICU, how do these figures interact or relate to the

   1     cardiac surgeon in the post-operative phase?
   2   A. Again, it depends on the organisation. If it is in
   3     a children's hospital, or within a children's unit, you
   4     have a paediatric intensive care unit to which the
   5     post-operative cardiac children went, then it is likely
   6     that you would have either paediatric anaesthetists or
   7     intensivists looking after those children afterwards.
   8        In a set-up where there are children and adults
   9     mixed together, not even in a big children's unit, then
  10     it is likely that adult orientated either intensivists
  11     or anaesthetists or whatever were looking after these
  12     children.
  13   Q. You are describing then a model in which the
  14     anaesthetists and the intensivists were in overall
  15     charge of the unit rather than, say, cardiac surgeons?
  16   A. Not necessarily. I think that the individual -- it is
  17     usually the intensivist who is in charge of the unit
  18     into which the cardiac surgeon puts his patient, but the
  19     name on the bed generally retained is the cardiac
  20     surgeon's. He has overall responsibility, usually, for
  21     that patient. The post-operative management, which is
  22     usually within a routine, as it were, within
  23     a guideline, a set of guidelines, is probably carried
  24     out and adjusted by the intensivist, according to how
  25     the patient is.

   1   Q. But with the ultimate responsibility remaining with the
   2     cardiac surgeon?
   3   A. I think that it probably does.
   4   Q. How is that responsibility handled or exercised when
   5     such a figure, or indeed, a consultant anaesthetist who
   6     has an operating responsibility, cannot obviously be
   7     within an ICU or be even available to go to an ICU at
   8     short notice if either of them are involved in
   9     operations?
  10   A. I think, as I say, the practical aspect of it will be
  11     managed by the intensivist, but the overall
  12     management -- because a lot of these patients are
  13     routine -- will be dictated by the cardiac surgeon or
  14     his practice, or whatever.
  15   Q. Is the interplay of responsibility between cardiac
  16     surgeon, consultant anaesthetist and intensivist
  17     something that you have seen changing over the last two
  18     decades, or has that been made a constant, in your
  19     experience?
  20   A. I think it is changing. I think in the better units,
  21     there was always a considerable amount of discussion and
  22     teamwork. But I think that certainly the concept of
  23     having a consultant intensivist, whatever their basic
  24     discipline, in the intensive care all the time, has
  25     become totally accepted now. Maybe ten years ago it

   1     would not have been, but it is, I think, now.
   2   Q. So ten years ago it would not have been generally
   3     accepted?
   4   A. It is difficult to know. I can only draw on personal
   5     experience here. As I say, it has not necessarily been
   6     the case everywhere else. We have had somebody doing
   7     intensive care, anaesthetists doing purely, virtually,
   8     all time intensive care for 11 years now.
   9   Q. Are you able to say how typical that experience would
  10     be, across other children's hospitals first?
  11   A. I think within the 10 year period it has become more and
  12     more common. Again, it is always quite difficult to
  13     persuade people paying the bills, i.e. the people
  14     actually financing the job, that you actually needed
  15     somebody in the intensive care, that somebody was not
  16     sitting around doing nothing for six sessions a week;
  17     they were actually working in the intensive care unit.
  18     If you cannot persuade the hospital management -- over
  19     the years it has changed its name -- that there is
  20     a need for this, then you will never get the post.
  21   Q. Now, does the membership of the Association of
  22     Paediatric Anaesthetists include people who will be
  23     described as intensivists, as well as --
  24   A. Yes, but not paediatricians. You do have to do
  25     anaesthetics, but an awful lot of our members do

   1     intensive care; whether they wish to describe themselves
   2     as intensivists or not, they do do a lot of intensive
   3     care.
   4   MISS GREY: Thank you, Dr Jones. It may be that the Panel
   5     may have some further questions.
   6             Examined by THE PANEL
   7   MRS MACLEAN: Just one, please. Could I ask a small point,
   8     which you may be able to help us with? I understood you
   9     to say that the APA currently has perhaps 25 paediatric
  10     anaesthetists working with cardiac patients?
  11   A. Full-time cardiac anaesthetists.
  12   Q. Would you have any information on how many such
  13     specialists there might have been ten years ago?
  14   A. Probably just a few less, because these people, like
  15     myself, come from big children's hospital itself that
  16     has always done cardiac anaesthesia for children, and
  17     I do not think that has changed dramatically. There has
  18     probably been an increase in numbers, slightly, but not
  19     in a huge way.
  20   MRS HOWARD: One question: you referred to your expectations
  21     in respect of surgeons discussing surgery with an
  22     anaesthetist prior to the operation taking place. You
  23     have talked about if it were not out of the ordinary
  24     then you would not expect a detailed discussion prior to
  25     operation.

   1        If a surgeon was developing a particular field of
   2     practice, would that be seen in your view as more
   3     towards the out of the ordinary, and would you have
   4     a view about your involvement in discussion in that
   5     situation?
   6   A. Yes, I would expect to have more involvement, especially
   7     if this was a learning experience and especially if this
   8     was a known high risk procedure, then I would expect to
   9     be consulted.
  10   PROFESSOR JARMAN: The reports talk about "occasional
  11     practice must not be undertaken". Could you clarify:
  12     would this mean one full-time operating list, or two
  13     sessions per week, at least?
  14   A. I think certainly one full list. That is two sessions,
  15     really. I would go for that. But I think that in
  16     certain specialties it perhaps would not always be
  17     possible. Certainly one session per week.
  18   PROFESSOR JARMAN: When it would be listed?
  19   A. It could be a morning or afternoon.
  20   THE CHAIRMAN: I have one observation, Miss Grey, it may
  21     help me. Transcript 58/17. I only draw attention to it
  22     because it is describing what might be the duties of
  23     a consultant anaesthetist, and you refer in your
  24     question to the risk of "surgery", and I am sure there
  25     you meant "anaesthetics"?

   1   MISS GREY: I did, yes, I am grateful for that, Chairman.
   2   THE CHAIRMAN: Just for the record, to clarify what the
   3     obligation may be. Thank you. I have no other
   4     question, if that was a question.
   5        Miss Grey?
   6   MISS GREY: There are no further questions that I have, but
   7     Dr Jones, if there is anything that you feel you would
   8     like to add to the evidence you have already very kindly
   9     given us this morning, please do so, whether you would
  10     like to do so now, or if at any stage the Association of
  11     Paediatric Anaesthetists wishes to contact us further to
  12     put in a supplementary statement or draw attention to
  13     any other features of the evidence which you have
  14     already given us today. Is there anything you would
  15     like to add.
  16   DR JONES: Nothing at the moment. I will obviously look at
  17     the transcripts which come up on the Internet. If there
  18     is anything I think needs clarification or I said
  19     wrongly, I will speak to you.
  20   MISS GREY: Thank you very much. Could I merely, in that
  21     case, thank you for having come along this morning.
  22     I expect the Chairman will have further words to add.
  23   THE CHAIRMAN: I echo those thanks on his behalf of
  24     the Panel and the view that if there is anything else
  25     you wish to let us know, we would be very grateful to

   1     hear from you at any time. Thank you for coming this
   2     morning.
   3            (The witness withdrew)
   4   THE CHAIRMAN: Mr Maclean, I would propose to go on now for
   5     half an hour, until 1.15, and then to take a break for
   6     half an hour, and then continue after that.
   7   MR MACLEAN: Yes. Could I call Dr Paul Lawler, please.
   8        Dr Lawler, I think you are going to give evidence
   9     on oath. Could I ask you to stand to take the oath,
  10     please?
  11            DR PAUL LAWLER (Sworn):
  12            Examined by MR MACLEAN:
  13   Q. An easy one to start with: could you give us your full
  14     name and your professional address?
  15   A. Paul Gerard Patrick Lawler. I work at South Keeble
  16     Hospital in Middlesborough.
  17   Q. You are there a consultant intensivist, I think?
  18   A. I am, sir, yes.
  19   Q. You are also, and have been since 1997, the President of
  20     the Intensive Care Society?
  21   A. Yes, that is correct.
  22   Q. You are a Fellow of the Royal College of Physicians and
  23     of the Royal College of Anaesthetists?
  24   A. Yes, sir.
  25   Q. You are a member of the Council of the Royal College of

   1     Anaesthetists and of the Intercollegiate Board for
   2     training in intensive care medicine?
   3   A. Yes, sir.
   4   Q. Could I have on the screen, please, document WIT 53/2?
   5        If we scroll down that page, please, that is the
   6     first page of the statement that you have submitted to
   7     the Inquiry, is it not?
   8   A. Yes, sir.
   9   Q. And if we turn to page 25, that is your signature?
  10   A. Yes, sir.
  11   Q. The aims of the Society, the Intensive Care Society, are
  12     set out at the first of those pages, page 2. It is
  13     right to say, is it not, that the Intensive Care Society
  14     is largely concerned with the care of adults rather than
  15     children?
  16   A. Certainly, the members are mainly adult intensive care
  17     doctors.
  18   Q. You tell us in the statement that the Society has
  19     published standards for intensive care three times in
  20     the relatively recent past, in 1974, 1984 and in 1997?
  21   A. That is correct.
  22   Q. And you probably know, Dr Lawler, that this Inquiry is
  23     centrally concerned at least with the events between
  24     1984 and 1995?
  25   A. Yes, sir.

   1   Q. So the 1984 standards therefore fall right at the start
   2     of the Inquiry's period. I just want to have a brief
   3     look at those. Could I have document ICS/1/141,
   4     please? Those are the Society's standards for 1984. If
   5     we go, please, to page 143, and if we can just blow up
   6     the second paragraph, please:
   7        "The Society commented in 1984 that there was at
   8     that stage:
   9        "Little general agreement about what constituted
  10     an intensive care or intensive therapy unit and how it
  11     should work. The Society was conscious of that
  12     deficiency and instructed its Council to prepare draft
  13     standards for the structure and services of an ICU."
  14        So these standards were essentially starting from
  15     a blank sheet of paper in terms of the appropriate
  16     standards?
  17   A. Perhaps not quite blank. There had been some standards
  18     put together by British Medical Association way back in
  19     1967, and there was a health building note around that
  20     time which gave the background of some of the practical,
  21     physical surroundings of intensive care.
  22   Q. That dealt with matters of how many power points there
  23     should be, the space between beds, fire regulations and
  24     matters like that?
  25   A. Much more the practical aspects of the design, the

   1     physical environment.
   2   Q. If we could look at the bottom of page 143, the
   3     penultimate paragraph, this is dealing with signs.
   4        "In 1984, we should not be looking for a detailed
   5     treatment of separate paediatric intensive care units,
   6     we are simply looking at general intensive care units
   7     where children may be treated as well adults."
   8        The penultimate paragraph says:
   9        "Units which are very large or small may be
  10     difficult to manage. Where more beds are required,
  11     consideration may be given to creating a separate
  12     intensive care unit for an identifiable group of
  13     patients, such as children, coronary disease, head
  14     injury, or burns patients, et cetera. There are,
  15     nevertheless, considerable advantages in grouping units
  16     in order to share specialist medical technical
  17     laboratory and engineering services."
  18        So what we get from that is that it was by no
  19     means unusual for children to be cared for in the same
  20     intensive care unit as adults in 1984?
  21   A. I think that is correct, that observation.
  22   Q. And secondly, that on occasion a particular medical
  23     problem, if I can put it like that, for example heart
  24     disease or head injuries or burns, might be, as it were,
  25     taken away from the general run of the hospital and

   1     hived off into a separate unit, where, presumably,
   2     adults and children would be treated alike?
   3   A. Yes, sir.
   4   Q. Now, this is a question asked of one or two witnesses
   5     already who have given evidence to the Panel. Are you
   6     able to comment or express a view on behalf of the
   7     Intensive Care Society as to whether or not, assuming
   8     one is starting from scratch, paediatric cardiac
   9     patients ought to be cared for with other heart
  10     patients, adults, or ought to be cared for away from
  11     adult heart patients but beside other paediatric
  12     patients?
  13   A. The Society does not have a view and I do not feel
  14     competent to be able to give one, because this is
  15     a paediatric area and I am not an expert in paediatrics.
  16   Q. We have looked very briefly -- we might come back to the
  17     1994 standards. If we go to the 1997 standards, we see
  18     there is a document ICS 1/1, please. These are the 1997
  19     standards published, I think, in May 1997.
  20        If we go to page 6, please, of that document, the
  21     first paragraph we see that the standards were intended
  22     to apply to adult, general intensive care units, so we
  23     are looking neither at specialist units, burns or
  24     neurosurgery, for example, nor paediatric:
  25        "Many parts of the document, particularly those

   1     relating to structure, are applicable to other areas
   2     offering a similar degree of care, such as
   3     cardiothoracic, neurosurgical or paediatric intensive
   4     care or high dependency care."
   5        So when looking at these standards we should bear
   6     that caveat in mind in an Inquiry which is concerned
   7     with paediatric intensive care and cardiothoracic
   8     surgery.
   9        If we go to page 8 of the same document, the
  10     second half of the page, the penultimate paragraph --
  11     just read the prepenultimate paragraph to give it some
  12     context:
  13        "Several international standards documents have
  14     been published [some of them are set out]. In the UK
  15     existing standards relate mainly to buildings, services,
  16     deployment of nurses and for some items of equipment.
  17     There have, however, been differences of opinion about
  18     the organisation, staffing and structure of what
  19     constitutes intensive care and it is now becoming
  20     increasingly important to draw together and direct
  21     standards which match the needs of patients and their
  22     carers."
  23        What I want to try and do this afternoon is to
  24     find out from you what the Society's view is about how
  25     intensive care ought to be organised, staffed and

   1     structured and, hopefully, by the end of asking you some
   2     questions that is what we will achieve.
   3        "The Department of Health has produced guidelines
   4     about which patients and what therapies should be found
   5     in the ICU. The importance of audit [we will come back
   6     to that] has also been emphasised, for example by the
   7     Intensive Care National Audit and Research Centre,
   8     ICNARC", which I think you are a member of?
   9   A. Yes.
  10   Q. "And the establishment of standards and guidelines for
  11     purchasers. The Intercollegiate Board on training for
  12     intensive care medicine..." and again you can help us
  13     with that, "... a multidisciplinary body, is also
  14     driving standards appropriate for those units who wish
  15     to provide training for medical practitioners in the
  16     acute specialties up to and including ICU directors."
  17        Before looking at the question of control when who
  18     runs an intensive care unit and who is responsible for
  19     the care of the patient there, a facile point, but it is
  20     one that we need to make. There is a range of
  21     expertise, medical expertise, required in any intensive
  22     care unit, obviously. What type of expertise would we
  23     expect to find in a paediatric intensive care?
  24   A. Broadly similar to that in an adult general intensive
  25     care unit, although the background of the doctor would

   1     be different. There will need to be a medical
   2     background in adult intensive care that would be adult
   3     medical practice. In paediatric practice, that would be
   4     paediatric practice.
   5        There will, at the same time, be a requirement for
   6     anaesthesia skills, and that would be applied to, both,
   7     again, we would have paediatric anaesthesia skills and
   8     adult anaesthesia skills, depending on each.
   9   Q. I wonder if I can put that answer into some documentary
  10     context? If we go to page 151 of ICS 1, this is a bit
  11     of the 1994 guidelines that I mentioned earlier.
  12        If we go to paragraph 3.1.1.3, "other medical
  13     staff", the top of the page talks about the consultants
  14     in the unit and then the junior medical staff.
  15        Could I ask you to read that paragraph from the
  16     beginning, "the patients", and tell me whether that is
  17     still an accurate reflection of the range of medical
  18     expertise in an intensive care unit? (Pause).
  19   A. I think that is a reasonable reflection of the present
  20     state of affairs, although I think it is certainly an
  21     adult general intensive care, the intensive care or the
  22     intensivist would actually start to take some decisions
  23     and not consult quite the number of other consultants in
  24     that list. But in the majority of hospitals in the UK
  25     there will not be a general intensivist, so the

   1     delegation or the -- delegation is a bad word -- drawing
   2     in of other consultants might be more frequent in some
   3     hospitals. Certainly in my hospital we will put chest
   4     drains in. The fact is that we have a thoracic surgeon,
   5     but we would not bother to call him.
   6   Q. You mentioned the word 'intensivist', and I think you
   7     would describe yourself as an intensivist in your
   8     hospital?
   9   A. I think I probably am now, yes.
  10   Q. Does the point you just made perhaps emerge at the foot
  11     of the same page, 3.1.4, "education and training", and
  12     remember this is 1984:
  13        "Consultants in intensive care need to be
  14     specialists in all aspects of acute medicine and
  15     resuscitation in the broadest sense...", and so on.
  16     Then it sets out the general professional training
  17     requirements. Then under the heading, "higher
  18     professional training":
  19        "The main emphasis in training is at a higher
  20     professional training level so no examination is
  21     required. (a) training should be pursued in conjunction
  22     with HPT requirements of the parent specialty and should
  23     in no way interfere with those requirements."
  24        Again, we see the phrase 'parent specialty' at the
  25     end of subparagraph B. Is that a reflection of the fact

   1     that in 1984 the consultants in the intensive care unit
   2     would be thought of as having a main specialty, a parent
   3     specialty, rather than being, as is now developing,
   4     consultant intensivists as such?
   5   A. That is true. Even now they will have a parent
   6     specialty, but they will spend more and more of their
   7     time in an intensive care unit, although that might not
   8     have been the case in the past.
   9   Q. To take an easy example, take yourself, your parent
  10     specialty is anaesthesia?
  11   A. Anaesthesia.
  12   Q. Could you perhaps flesh out these guidelines for 1984 by
  13     reference to your own experience and tell us how you
  14     started off as a medical student, and then an
  15     anaesthetist, and ended up today describing yourself as
  16     an intensivist?
  17   A. There was no training in intensive care at that stage,
  18     and --
  19   Q. What stage is that?
  20   A. This was when I was qualified, which was 1969, and --
  21   Q. I am sorry you had to give your age away.
  22   A. I have not. I qualified in 1969. By 1972 I knew I was
  23     going to be an intensive care doctor. At that stage,
  24     I was doing general medical training and it was obvious
  25     that intensive care units at that stage were largely

   1     respiratory care units run largely by anaesthetists.
   2     I therefore completed my general professional training
   3     in medicine and obtained MRCP, which was not unusual.
   4        I then switched to anaesthesia, and undertook
   5     general professional training in anaesthesia, and higher
   6     professional training in anaesthesia, and that route was
   7     not an unusual route, or that route has not become,
   8     subsequently, an unusual route; it was very unusual at
   9     that stage.
  10        So that is the pattern that I went through, and
  11     I became a consultant in 1979, before there was any
  12     additional training for intensive care. I had
  13     structured my own training pattern for that.
  14   Q. When you became a consultant in 1979, you were
  15     a consultant in an intensive care unit?
  16   A. Yes. I spent nearly four years sitting in an intensive
  17     care unit doing some anaesthesia, doing a research post,
  18     which allowed me to essentially run an intensive care
  19     unit rather than doing research. So I picked my
  20     intensive care training up in that way, very much
  21     ad hoc, but that was not unusual in those days.
  22   Q. So you have essentially been in that same consultant
  23     post since then, 20 years ago?
  24   A. I spent most of my time pretending to be a consultant
  25     while I was a Senior Registrar!

   1   Q. I think we can leave the Panel to draw its conclusions
   2     from that comment.
   3        Just while we are dealing with consultants in the
   4     intensive care unit, if we go to the 1997 standards, the
   5     Intensive Care Society's document, ICS 1/43, this is
   6     under the general heading of "Operational
   7     Recommendations", it says:
   8        "A designated consultant should bear
   9     administrative responsibility for the unit [we will come
  10     to that in a moment]. In many Trusts this will be the
  11     clinical director, but if not, a lead consultant should
  12     be appointed with responsibility for clinical policies,
  13     staffing, audit, and have input into budgetary
  14     controls. Specific sessions set aside for
  15     administrative and management will be required if the
  16     unit has four or more beds. Clinical responsibility [as
  17     opposed to administrative responsibility] may be shared
  18     by more than one consultant, but excessive numbers may
  19     jeopardise continuity of care."
  20        Leaving out the next paragraph and going to the
  21     third paragraph:
  22        "The Society recommends that the minimum weekly
  23     allocation for consultant sessions for an ICU of four or
  24     more beds should be 15, of which 10 should reflect fixed
  25     daytime sessions. A minimum of seven consultant fixed

   1     daytime sessions dedicated exclusively to the practice
   2     of intensive care medicine is required to achieve
   3     training recognition. In larger units it may be
   4     necessary to have two simultaneous consultant sessions
   5     with up to 15 fixed daytime sessions allocated."
   6        This is the bit I want to probe a little:
   7        "The impact of the reduction in trainees' hours of
   8     work, coupled with the Calman training proposals,
   9     suggests that the need for two consultants
  10     simultaneously is increasing in order to provide
  11     adequate clinical and technical skills. Large units may
  12     require up to 30 consultant sessions per week not only
  13     to cover daytime commitments but also to cover nights,
  14     weekends and periods of leave. Some of these daytime
  15     sessions may be shared with other duties ..."
  16        We have already established that you are a member
  17     of the Intercollegiate Board for training in intensive
  18     care medicine, and I know you have a degree of knowledge
  19     of the changes that have been brought about to training
  20     for intensive care.
  21        That sentence in the middle of that
  22     paragraph referred to two separate factors being at
  23     work, one being the reduction in trainees' hours and the
  24     other being the mysterious beast knows as 'Calman'.
  25        Can you explain what the impact of each those has

   1     been and how it has come about that we might need,
   2     according to this Standards document, more consultants
   3     as a result of those two factors?
   4   A. Unit doctors or trainees, as they are now rightly
   5     referred to, in the past would work 100 or so hours
   6     a week, not all of it working, some of it sleeping.
   7     Nevertheless, they were available for that time. Not
   8     unreasonably, they wanted a family life of sorts, and
   9     there were also European directives on hours.
  10        The consequence is that junior doctors' hours,
  11     trainees' hours, have been cut from around 100 to around
  12     50; in other words, their hours have been cut in two.
  13        Calman training proposals have streamlined
  14     training from the sort of training I did, which took 10
  15     to 11/12 years, down to 5 or 6 years.
  16   Q. That is in order to reach consultant level?
  17   A. Yes, so from qualification to becoming consultant was
  18     between 10 and could be 15 years in some
  19     superspecialties. Now it is down to 6 or 7.
  20   Q. Superspecialties would include, what, paediatric cardiac
  21     surgery?
  22   A. It could include paediatric cardiac surgery or
  23     paediatric anaesthesia, paediatric cardiology,
  24     specialties where there will be naturally a small
  25     workload, so there is not a huge need for numbers of

   1     consultants.
   2   Q. And hence the number of available training posts will be
   3     small?
   4   A. Yes, but to get back to my original point, the
   5     trainees hours have been cut in two. Their training
   6     time, years, have been cut in two, so they are not
   7     available. So they are relatively under-trained but
   8     there is also no-one on the floor. If they are not
   9     there, someone else has to do the work. If you halve
  10     the number of hours, you have to double the number of
  11     people. Someone has to do that job and they have to be
  12     trained. Certainly some of my training I absorbed and
  13     was not trained; I found out myself. Now with the
  14     training cut in two, there is a lot of very active
  15     teaching: do not look at the book; teach them quickly,
  16     so they are force-fed. Trainees are now at least being
  17     partly force-fed something that I absorbed over years.
  18   Q. So the reference in the document to needing more
  19     consultants is simply in order to get through the work?
  20   A. Once upon a time, the service, the workhorses, were the
  21     trainees. Now the workhorses are going to be the
  22     consultants, who also have to teach the trainees
  23     quicker, so some of the consultant's time now is
  24     actually positively teaching something which one hoped
  25     we learned in the past.

   1   Q. I want to move to an issue I touched on briefly, which
   2     is control of the intensive care unit.
   3        If we look at the 1984 standards, page 154, it is
   4     at the foot of the page, under the heading "Unit
   5     administration and operational policies, clinical
   6     management":
   7        "This may be of two different patterns. The
   8     actual arrangement adopted should be defined, agreed and
   9     understood by all the consultants concerned. In either
  10     case, routine management should be prescribed and
  11     supervised by unit medical staff. Decisions of a more
  12     specific nature should be taken in consultation with the
  13     referring clinician."
  14        There are two models then set out. The first, on
  15     this page:
  16        "Intensive care consultants may have complete
  17     clinical responsibility for the care of patients
  18     admitted to the unit. They take over when the patient
  19     is admitted [to the unit] and may transfer care to
  20     another appropriate consultant at the time of
  21     discharge. In this case, the consultant who originally
  22     admitted the patient to hospital may continue to act in
  23     a purely consulting capacity. Consultants from other
  24     specialties may also be invited to give advice.
  25         "This arrangement is well suited to units in

   1     which the patients are from a very homogenous group,
   2     such as neonates with head injuries, myocardial infarcts
   3     or renal failure, and those who have had cardiac
   4     surgery."
   5        I am going to ask you about these models in
   6     a minute.
   7        If we go over the page to 155, the top of the
   8     page:
   9        "Alternatively, the patients are admitted to the
  10     intensive care unit under the care of their admitting
  11     consultants and remain so throughout their stay."
  12        So if you are admitted for a heart operation, the
  13     heart surgeon.
  14         "The ICU consultants are usually deemed to be in
  15     consultation, but the extent of their responsibility
  16     will be agreed locally."
  17        If we go to page 137, please, still on the same
  18     point, this is part of a survey carried out by the
  19     Association of Anaesthetists of Great Britain and
  20     Ireland, a document you have supplied, I think, to the
  21     Inquiry.
  22        If we go to 137 and turn it around, at
  23     paragraph 3.6, the foot of the left-hand column:
  24        " ... in 85 per cent of the units ... surveyed,
  25     the consultant in administrative charge was an

   1     anaesthetist, and a physician or clinical physiologist
   2     in 10.5 per cent of cases. A surgeon fulfilled this
   3     role in three units, and in seven no nominated
   4     individual could be identified.
   5        "Consultant clinical care [which we are concerned
   6     with] in ICUs was undertaken jointly by an anaesthetist
   7     and the referring clinician in 84 per cent of units.
   8     In only 13.6 per cent was this care provided by one
   9     consultant alone."
  10        2.3 per cent of respondents could not answer the
  11     question.
  12        Then, just to see how matters progressed, at
  13     ICS 1/43, a 1997 Standards document from the Intensive
  14     Care Society -- we saw this page a moment ago. The
  15     first paragraph ends by saying:
  16        "Clinical responsibility may be shared ..."
  17        If we go to page 51, again, these are the same two
  18     patterns, but they have now been given labels of
  19      "closed" and "open"?
  20   A. Yes, that is true.
  21   Q. A closed unit is a unit where the intensive care
  22     consultant is completely responsible for clinical
  23     management. An open unit is a unit where the clinical
  24     management remains the responsibility of the admitting
  25     consultant.

   1        If we go to the second paragraph under 4.1.1(b),
   2     it says this:
   3        "This arrangement [the open arrangement] is better
   4     suited to general intensive care units serving a wide
   5     range of admitting specialties, none of which could
   6     sustain their own dedicated unit. Units in which the
   7     intensive care consultant has had a high degree of
   8     autonomy and control of patients in the intensive care
   9     environment have been consistently shown to produce
  10     better patient outcomes."
  11        Is that research which has been done in this
  12     country or abroad?
  13   A. They are both American. The Knaus paper is probably one
  14     you will come to at a later stage. That refers to
  15     APACHE scoring, which you have probably heard of.
  16   Q. We will come to APACHE.
  17   A. From the details coming out from the APACHE scoring, it
  18     looked as if the difference between the good outcome
  19     units and the not so good outcome units was more related
  20     to the quality of the administrative side rather than
  21     the quality of the toys, as we call them, "toys" being
  22     the equipment: "it is the boys that matter not the
  23     toys". That was quite clear: that a single dedicated
  24     director, a dedicated nursing staff, low staff turnover,
  25     were much more effective in producing a good outcome

   1     than the number of fancy toys they had, but often that
   2     sort of unit, because it was fairly well directed, often
   3     by a "Fat Controller", would usually get the toys too.
   4   Q. I am sure those answers will appear verbatim in the
   5     Inquiry's report. I am sure the Chairman will be happy
   6     to put his name to that sentence!
   7        This research in the United States: has that been
   8     replicated anywhere else?
   9   A. In terms of outcome and closed and open units, yes.
  10     It looks consistently that closed units have a better
  11     outcome in terms of patient outcome; they are more
  12     efficient in terms of money spent on patients per
  13     outcome, so overall, closed units are cheaper and the
  14     outcome is better.
  15   Q. What is the pattern in the UK? What has been the
  16     pattern in the UK over the last 15 years? Do units tend
  17     to be open or closed?
  18   A. Units are more likely to be open in the UK.
  19   Q. Why?
  20   A. Because there are no dedicated intensive care doctors
  21     who have the time on the unit and also have the time to
  22     go to hospital meetings to bang their fists on the
  23     table.
  24   Q. Does that take us back to training again: that there is
  25     a lack of people with the requisite training who would

   1     have the ability to run a closed unit? Is that the
   2     point?
   3   A. Part of it is that there is a lack of training, but
   4     there is also the number of sessions involved. Most
   5     intensive care units, even now in the UK, do not have
   6     a full sessional commitment from consultants; often
   7     they only have six or seven consultant sessions a week.
   8     That is not a full post. If there are going to be two
   9     people, those consultants have to do something else.
  10   MR MACLEAN: Dr Lawler, I think I am about halfway through.
  11     Is that a convenient moment to take a short break?
  12   THE CHAIRMAN: I am grateful. Why do we not take a half an
  13     hour break now, therefore and reconvene at 1.45?
  14   (1.15)
  15            (Adjourned until 1.45 pm)
  16   (1.45 pm)
  17   MR MACLEAN: Dr Lawler, before lunch we were dealing with
  18     the open and closed management structure for intensive
  19     care units. In your statement at WIT 53/8, you say in
  20     paragraph 2.4.2:
  21        "This pattern of working [the closed pattern] is
  22     normal in some countries, e.g. Australia, New Zealand,
  23     parts of Europe, some parts of the US."
  24   A. I believe that closed units are almost invariable in
  25     Spain but less so in other parts of Europe. I believe

   1     there are closed units in France, Belgium, Holland,
   2     Germany. They are almost invariable in Spain, where
   3     intensive care is a specialty in its own right.
   4   Q. It is the development of intensive care as a specialty
   5     in its own right that tends to drive forward the process
   6     of moving from open to closed units.
   7   A. Yes.
   8   Q. If we look down that page at 2.4.4, you deal with
   9     specialised units, for example, those only admitting
  10     post-operative cardiothoracic patients:
  11        "They might have a different kind of structure or
  12     an open structure, with the admitting consultant who
  13     would often have a high personal unit throughput, being
  14     in overall clinical control throughout the patient's
  15     stay. There could be blurring of responsibilities
  16     between theatre clinical care, immediate post-operative
  17     care and intermediate care, before the patient would be
  18     discharged from the ICU to the HDU or ward. In general,
  19     however, in whatever unit is envisaged, the intensive
  20     care consultant will be responsible for clinical
  21     management of aspects of ventilatory support. Aspects
  22     of clinical care of the circulation, on the other hand,
  23     may fall between several specialists: the intensive care
  24     doctor, the cardiologist and the cardiothoracic
  25     surgeon."

   1        So even in units which are open, perhaps for good
   2     reason, perhaps because they are specialist
   3     cardiothoracic units, the intensive care consultant
   4     would still be in, if not sole, then primary clinical
   5     control of the ventilatory support of intensive care
   6     patients?
   7   A. That is rather like the cardiologist will be in control
   8     of the cardiovascular system, so the intensive care
   9     doctor, his area of expertise just happens to be
  10     ventilation. That is a very wide open unit.
  11   Q. Over the page, please, to page 9, paragraph 2.4.6:
  12        "Currently [we are now in the UK] there is a move
  13     towards semi-closed units where the patient, although
  14     nominally under clinical care of the intensive care
  15     consultant, is managed jointly with the intensive care
  16     consultant only taking absolute control when there is
  17     clear conflict of advice".
  18        So ultimately, somebody has to take a decision if
  19     there is a split between two people with joint care, and
  20     you are suggesting in the semi-closed unit that person
  21     with ultimate control would be the intensive care
  22     consultant or intensivist?
  23   A. It is not usually a conflict of two, it is a conflict of
  24     three and someone has to make a decision: the three
  25     consultants involved in the care of the patient. For

   1     instance, the intensive care doctor who might be
   2     managing the respiratory side, the cardiologist managing
   3     the heart side and the nephrologist who is managing the
   4     kidneys. So the heart chap says "We require to take
   5     fluid off the patient". The nephrologist says "We need
   6     to give the patient fluid". The intensive care doctor
   7     does not mind, but someone has got to make a decision
   8     because there is a clear conflict: One says "give
   9     fluid" and the other says "remove it".
  10   Q. The next paragraph in your statement, we can see what it
  11     says, but implicit in that is the fact that the
  12     Intensive Care Society is aiming towards general units
  13     with a variety of patients, so that would mean that it
  14     was more likely that those units would be managed in an
  15     open or semi-closed way, rather than a closed way?
  16   A. I think "semi-closed" would be the phrase used. That
  17     would appear to be more effective in output terms.
  18   Q. Where a unit is a specialist cardiac unit, for example,
  19     that would be the type of unit that would be, in
  20     principle, best amenable to a closed system of
  21     management?
  22   A. That is right.
  23   Q. So, although I asked you before lunch what structure you
  24     would see for something as specialised as paediatric
  25     cardiac surgery and you said that was not really your

   1     department, if it were the case that paediatric cardiac
   2     surgery were best managed in a separate unit, perhaps
   3     with adult cardiac patients as well, that would be the
   4     type of unit that would lend itself to a completely
   5     rather than semi-closed system of management?
   6   A. This is a single organ unit, dealt with by single organ
   7     doctors. They are all dealing with the same organ.
   8     They should at that stage have a combined management
   9     pattern. They dealt with each other from the moment the
  10     patient was admitted to the hospital. There is
  11     a continuum of care. Most patients admitted to general
  12     intensive care units are unexpected, unexpected
  13     emergencies dealing with a variety of consultants. When
  14     I left my unit yesterday, there were eight patients with
  15     a different consultant attached. That is very unlikely
  16     in a cardiac or cardiothoracic unit.
  17   Q. Picking up that point in the 1997 standards produced by
  18     the Intensive Care Society, at WIT 53/23 -- this is your
  19     statement, still, we will come to the standards in
  20     a minute -- you make the point in G4 that planning for
  21     staff numbers is more difficult in a general intensive
  22     care unit, whether adult or paediatric, than in
  23     a specialist one and that is because the specialist unit
  24     is bound to have a much higher percentage of elective
  25     rather than emergency patients?

   1   A. That is correct. As a result the pattern of problems
   2     would also be planned. There will be an expected
   3     pattern of problems.
   4   Q. The patient next Tuesday is coming for X?
   5   A. The anaesthetist, cardiologist and cardiothoracic
   6     surgeon would all know what the expected problems were.
   7   Q. If we just go to how that knowledge would be imparted
   8     around the unit, if we go to the 1997 standards, ICS
   9     1/56. This is a passage in the 1997 standards which
  10     deals with, amongst other things, staff meetings in the
  11     intensive care unit. The bottom half of the page, if
  12     you scroll down a little:
  13        "There should be regular, preferably weekly
  14     meetings and discussions amongst the medical nursing and
  15     other professional staff associated with the unit to
  16     deal with management problems ...
  17        "(b) a review of cases and patient management
  18     both within the unit and in conjunction with other
  19     departments, teaching sessions for nurses, doctors and
  20     students..." and then the business rounds.
  21        It is (b) there that goes to the point you have
  22     just been discussing, is it not, that the unit would
  23     have regular meetings, especially within an elective
  24     base unit like paediatric cardiac surgery and intensive
  25     care. There would be meetings, what, the week before

   1     reviewing who was liable to come through the door the
   2     following week?
   3   A. They are usually done on a Friday afternoon, I believe,
   4     to check out what is going to come through the following
   5     week.
   6   Q. To take cardiac surgery, if the surgeons had regular
   7     meetings with the cardiologists planning the following
   8     week's theatre list, what role would or ought the
   9     intensivist to have in those discussions, looking at
  10     next week's list?
  11   A. I know what happens in my own cardiothoracic intensive
  12     care unit. I cannot speak for everywhere, but they are
  13     fully involved and present throughout those meetings.
  14     There is a combined meeting of the cardiologist, the
  15     cardiothoracic surgeons and the intensive care doctors
  16     who all happen to be anaesthetists, on a Friday
  17     afternoon.
  18   Q. Can I turn, then, to another topic, the topic of
  19     nursing? Could I have ICS 1/138, please? This is the
  20     Association of Anaesthetists of Great Britain and
  21     Ireland report from 1988. They conducted a survey at
  22     that time. Could I have the left-hand column, please,
  23     begin at the second paragraph, and the next one,
  24     please.
  25        What the Association said was this, picking it up

   1     halfway down the first of those paragraphs:
   2        "Data in the survey on bed numbers and admissions
   3     are difficult to evaluate. Before any assessment of the
   4     cost-effectiveness of intensive care can be made,
   5     information is needed about the number of in-patient
   6     days and illness severity scores, such as APACHE. Such
   7     information is probably not available from a majority of
   8     units [this is 1988]. However they are necessary before
   9     a reliable audit of intensive care can be carried out.
  10        4.3: "An ICU is intended for the care of patients
  11     who need and can benefit from more care than is
  12     available from the hospital as a whole. This service
  13     includes not only the provision of technological support
  14     and invasive monitoring, but also constant skilled
  15     medical and nursing care. The replies on nursing
  16     numbers are disturbing, if not unexpected. Above all
  17     things, intensive care demands safe numbers of properly
  18     trained nurses. This is commonly understood to mean one
  19     nurse per patient at all times, together with adequate
  20     numbers of supervisory and ancillary staff. Some
  21     patients require the attention of more than one nurse
  22     and a dependency nursing scoring system has been
  23     proposed. The need for appropriate training is
  24     recognised by the English National Board by the
  25     provision of courses in intensive care nursing. Trained

   1     intensive care nurses are an elite where work is
   2     demanding and sometimes stressful."
   3        I think the Intensive Care Society has suggested
   4     in the 1997 standards -- we saw a bit of this from the
   5     Paediatric Intensive Care Society last week -- that the
   6     number of whole-time equivalents per bed in an intensive
   7     care unit is at least 6.3 or 6.4; is that right?
   8   A. Probably more like 7.
   9   Q. If we look at ICS 1/46, the paragraph just above 3.2.1,
  10     two-thirds of the way down the page, do you see that
  11     paragraph beginning:
  12        "The staffing requirement necessary to provide
  13     a nurse at the bedside at all times is at least 6.3."
  14        That is the figure I have just used.
  15        If we read on, however, three sentences, we get to
  16     the figure you used and the explanation for why 6.3 is
  17     actually too few.
  18   A. 6.3 assumes a bed occupancy of around 70 per cent. It
  19     assumes that the nursing staff, on that age between 20
  20     and 50, the consequence of occupancy is 80 per cent
  21     between and a high proportion of nurses becoming
  22     pregnant, taking maternity leave and then returning to
  23     part-time work, which is quite common now, is that you
  24     need often over 7 nurses per bed. I currently have one
  25     and a half beds down because my nursing staff are on

   1     maternity leave.
   2   Q. The expectations in terms of the level of training of
   3     nurses dealing with children in intensive care units,
   4     whether specialist paediatric unit or a general unit,
   5     has developed enormously since the mid-1980s?
   6   A. Yes.
   7   Q. If we look to the 1984 standards, page 154, the top of
   8     the page, it says:
   9        "There should be a senior nurse with several years
  10     experience in charge of the unit supported by similarly
  11     experienced sisters or charge nurses. Fully qualified
  12     nurses who have completed a recognised course of
  13     training ... should form the core of the staff. It is
  14     beyond the scope of this document to specify training
  15     requirements in more detail ..."
  16        If we just then go ahead to page 47, the 1997
  17     standards, that recommendation from the mid-1980s has
  18     been beefed up. It now reads:
  19        "It is suggested that at least 25 per cent of
  20     senior nursing staff should hold a formal qualification
  21     related to intensive care ... Those units who are
  22     involved in providing members of a cardiac arrest team
  23     may require advanced life support ..."
  24        Why should there have been this development in the
  25     expectations of the qualifications of nurses over

   1     a relatively short period of time?
   2   A. In the development of intensive care we are aeons away
   3     from 1984, it has turned over completely, so the need
   4     for skill and knowledge is quite different from 15 years
   5     ago.
   6   Q. Why has it moved aeons?
   7   A. We have technology which was not available. Simple
   8     straightforward technology, not put together with string
   9     and sealing wax. Equipment works, and there are
  10     a variety of treatments which are now available in many
  11     intensive care units which were not available even in
  12     teaching hospitals 15 years ago, so the change is
  13     dramatic.
  14        So the need for a higher quality of nurse -- I am
  15     not talking about care, I am talking about technical
  16     skills, education -- is quite different from what it was
  17     20 years ago, where nurses were often more carers than
  18     technologists. I am not denigrating caring now, I am
  19     saying there is a greater need for technical skill now
  20     than there was before.
  21   Q. Given that there is now a greater need for greater
  22     technical skill on the part of the nurses, is that skill
  23     readily available?
  24   A. It depends where you go. Certainly in the south of
  25     England there appears to be problems with recruitment of

   1     adequate numbers of adequately skilled nurses. The
   2     further north you go, there are different problems.
   3     There remain problems getting those nurses at the
   4     bedside. For me it is a problem of money. In the south
   5     of England, it does not matter how much money you have,
   6     there are no nurses.
   7   Q. Is that because in the south of England people with
   8     those qualifications do not want to become nurses
   9     because the pay is not good enough?
  10   A. The pay is not good enough. When you live in a high
  11     unemployment area such as I do, the nurse may be the
  12     breadwinner.
  13   Q. So you have the potential supply?
  14   A. I have the supply.
  15   Q. But not perhaps always the money to purchase it?
  16   A. No money to purchase it. The 25 per cent down there was
  17     one of the suggestions, or one of our thoughts is that
  18     there should be no intensive care unit of less than four
  19     beds, so that puts one nurse on the floor who is
  20     adequately qualified at all times.
  21   Q. The Intensive Care Society produced a document in 1990
  22     called Intensive Care Audit, which you have supplied to
  23     the Inquiry. If we go to 115, please, hopefully we will
  24     see the introduction to that document. The fifth
  25     paragraph down says:

   1        "Nurse shortages are responsible for many units
   2     working below capacity. The reasons are many, but units
   3     with inadequate nursing establishments find retention of
   4     staff difficult because of the pressures of constantly
   5     working short-handed. Records of nurse workload and
   6     staffing levels are therefore as important as clinical
   7     data."
   8        Is that a pattern that is still the position
   9     today? This was 1990.
  10   A. I think that is true, yes.
  11   Q. Is there any empirical research to suggest either that
  12     way or the other way?
  13   A. I think there is some. I believe that in units who are
  14     running 12-hour shifts, a shift pattern of 12 hours,
  15     where the stress level for the nursing staff is higher,
  16     their sickness rate is higher, so there is some evidence
  17     that stressed units lose their staff, in a very
  18     round-about way. I do not believe the audit commission
  19     data is in the public domain yet.
  20   Q. That passage there tells us that one of the things that
  21     ought to be recorded is nurse workload and staffing
  22     level. I want to turn to the question of recording data
  23     and statistics in audit. If we just go over the page,
  24     please, to 116, this, I repeat, is a 1990 document from
  25     the Intensive Care Society. It says in the third

   1     paragraph:
   2        "The APACHE II system overcomes the problem of
   3     data interpretation since it gives a measure of severity
   4     of illness at admission to ICU. Information on severity
   5     of illness is an essential part of ICU audit. The ICS
   6     APACHE II database of patients continues to grow, and it
   7     is likely that this data will offer the best estimate of
   8     an ICU outcome in the UK for the foreseeable future.
   9     Any audit should therefore include an APACHE II score on
  10     admission to ICU but this single score should not be
  11     used to assess prognosis in individual patients."
  12        Just pausing there, the APACHE II system is
  13     designed to, as it were, take a snapshot of the illness
  14     of the patient when they enter the intensive care unit
  15     so the performance of that unit rather than the hospital
  16     as a whole can be recorded and assessed. Is that
  17     broadly right?
  18   A. In as much as the hospital can damage the patient after
  19     discharge from the intensive care unit, APACHE
  20     absolutely looks at the severity of the patient's
  21     condition at admission, when it is in the worse
  22     condition. It then projects the likely outcome of that
  23     patient. That assumes that all care is given all the
  24     way through and is the best care, and it is usually
  25     recognised that this will -- the implicit assumption is

   1     that intensive care, or lack of it, is the most likely
   2     area of care to affect outcome. But patients who are
   3     discharged from intensive care early have a higher death
   4     rate than patients who are discharged at the best time.
   5     That information is also not in the public domain.
   6     Patients who are discharged from intensive care units
   7     during the night, as an urgency to make way for other
   8     patients, do appear to have a higher death rate than
   9     those who are not discharged or who are discharged in
  10     daytime, which clearly suggests that the outcome of
  11     intensive care does not depend solely upon the intensive
  12     care unit but also depends on other factors, such as
  13     care on the wards.
  14        The implicit assumption in the APACHE system is
  15     that it is the intensive care unit's fault.
  16   Q. You have referred to that information as "not in the
  17     public domain". Where is it?
  18   A. It was presented last week to the annual general meeting
  19     of ICNARC, the Intensive Care National Audit Research
  20     group, by the director of that group. I believe it will
  21     be published in the next 6 months.
  22   Q. Just in time for the Inquiry to look at audit in some
  23     detail.
  24        APACHE is Acute Physiology, Age and Chronic Health
  25     Evaluation?

   1   A. Yes.
   2   Q. WIT 53/18, please. It is the footnote at the bottom of
   3     the page that explains what APACHE is. In
   4     paragraph A.1, you explain APACHE and you explain:
   5        "Case mix adjustment means expected outcome can be
   6     considered in the light of the severity of illness and
   7     the illness itself. For critically ill patients the
   8     question is whether the death rate is better or worse
   9     than the calculated average for the case mix. APACHE
  10     case mix adjustment should not at present be applied to
  11     children of 16 years and under. The paediatric
  12     equivalent, PRISM, paediatric risk of mortality, is less
  13     well validated. Assessing expected outcomes from
  14     intensive care is an inexact science."
  15        Several questions from that. First of all, when
  16     did APACHE come on the scene for adult intensive care
  17     case mix measurement?
  18   A. APACHE came on the scene in 1980. APACHE II came on the
  19     scene in 1985 and started being used in the UK in 1986
  20     and the Intensive Care Society's APACHE II, the UK
  21     derivation of APACHE II appeared in 1993, I think it
  22     was.
  23        The UK equation, getting from the severity of
  24     illness score and illness to an outcome requires
  25     a complicated equation. There was a rerun of the

   1     American system in the UK in the early 1990s, and the
   2     equation was modified to take into account the slight
   3     differences in outcome in adult general intensive care
   4     units in the UK, which differed from the US: not much.
   5   Q. If that is when APACHE came on the scene, do you
   6     remember we looked at that document from the Association
   7     of Anaesthetists of Great Britain and Ireland, page 138,
   8     and you will remember that that said, having mentioned
   9     APACHE:
  10        "Such information [information about the number of
  11     in-patient days and illness severity scores] is probably
  12     not available from the majority of units. However, they
  13     are necessary before a reliable audit of intensive care
  14     can be carried out."
  15        Why should it be that in 1988, with the APACHE
  16     system there, which could potentially adjust for case
  17     mix, that the Association of Anaesthetists of Great
  18     Britain and Ireland was finding that the information was
  19     probably not available from the majority of units?
  20   A. It was down to the manning of intensive care units,
  21     because at that stage, the majority -- again I come back
  22     to adult general intensive care units -- did not have
  23     many sessions allocated, consultant care allocated, and
  24     in fact even a couple of years ago, there were intensive
  25     care units in the UK who had no intensive care sessions

   1     allocated to a consultant. There is a study by Metcalfe
   2     and McPherson of intensive care units, I think in 1993,
   3     published in 1995, which noted that on one day, no
   4     consultant was seen in the intensive care unit in about
   5     50 per cent of the intensive care units in the UK. That
   6     is because there are no sessions in intensive care,
   7     which is a comment on the quality or the numbers of
   8     consultants available to look after intensive care units
   9     in the UK.
  10   Q. Having dealt with APACHE, I come back to your
  11     statement. You say that APACHE should not at present be
  12     applied to children of 16 years and under.
  13        Why does APACHE not work for children?
  14   A. It was set up against adults. The data came from
  15     adults. Intensive care illnesses -- children have
  16     different illnesses from adults. It is a statistical
  17     system: you require large numbers to come out with the
  18     statistical outcome, so the numbers were not there, and
  19     perhaps the illnesses were different.
  20        So there has been, and I think is still ongoing,
  21     a move to apply APACHE to children in the UK -- I do not
  22     think that has been completed, it is being undertaken by
  23     ICNARC. But there is an equivalent, which is PRISM, but
  24     I do not know enough about PRISM -- that is the
  25     Paediatric Risk of Mortality Index.

   1   Q. You mentioned ICNARC once or twice, which was founded in
   2     1994?
   3   A. Yes.
   4   Q. It stands for Intensive Care National Audit and Research
   5     Centre?
   6   A. Yes.
   7   Q. You make a grand claim for ICNARC in your statement. If
   8     we go to WIT 53, page 5, paragraph 1.9. You say five or
   9     six lines down:
  10        "The Society [Intensive Care Society] was
  11     instrumental in setting up this organisation which
  12     provides the highest quality audit data in the world."
  13        What is the basis of that claim?
  14   A. The data that goes into ICNARC is validated to the
  15     extent that for intensive care clinicians who have to
  16     give the data to ICNARC, they get a bit mad with it
  17     because the data is rejected so often as being
  18     inadequate in quality, so every piece of information
  19     that comes out of ICNARC is of the highest quality. The
  20     age is correct, and so on. The data validation routines
  21     in the system can cause rejection of that data five
  22     times. If you are the intensive care that is providing
  23     that data, you get a bit unhappy.
  24   Q. If we go to the 1997 standards, page 57, first of all,
  25     the first paragraph says:

   1        "Details of the numbers of cases treated, illness
   2     severity, age, outcome and treatments must be recorded."
   3        They should be analysed at regular intervals.
   4        "The Intensive Care Society has provided details
   5     of the minimum data set necessary for audit ...
   6     Ideally, units should subscribe to ICNARC in order to be
   7     able to relate their performance against a larger group
   8     of ICUs."
   9        How does subscription to ICNARC work? It suggests
  10     from that paragraph that units need not trouble
  11     themselves with ICNARC if they do not want to; is that
  12     right?
  13   A. There is no requirement to join an external audit
  14     organisation.
  15   Q. How would a unit decide to subscribe to ICNARC? Who
  16     would take that sort of decision?
  17   A. Usually the clinical director would want to have his
  18     performance analysed, there is quite an interest in
  19     audit in intensive care. What happens next is, you
  20     approach ICNARC, say you would like to join; they will
  21     put you through a training period and then ask you to
  22     fill in lots of data, which will be rejected.
  23   Q. If there is a unit which decides not to join ICNARC,
  24     does that mean that those operating ICNARC do not know
  25     what the performance of that unit is?

   1   A. Nobody knows what the performance of that unit is, other
   2     than the people there, if they choose to perform the
   3     sort of audit we are talking about.
   4        APACHE II, a means of assessing outcome, is in the
   5     public domain, so the equation is in the public domain,
   6     so you can compare yourself with US outcome, but there
   7     is nothing to say your data has been collected
   8     correctly, so the validation of the data is poor. We
   9     know that is poor because ICNARC look at the data and
  10     reject it so often, and so if you are doing your own
  11     audit, you will not reject your own data.
  12   Q. So how many general adult intensive care units in the
  13     country do subscribe to ICNARC?
  14   A. 132.
  15   Q. How many do not?
  16   A. 287. You can do the sums.
  17   Q. It is a bit less than 50 per cent?
  18   A. About 50 per cent.
  19   Q. Mr Langstaff tells me it is 155.
  20   A. That is correct.
  21   Q. If you go over the page to 58, please, what it says at
  22     the foot of the previous page is:
  23        "Items recommended to be collected for the basic
  24     analysis of the work of an ICU have been listed
  25     previously. Data are collected around the time of

   1     starting intensive care and are based upon the APACHE II
   2     and TISS methods".
   3        Then information is collected on all those items
   4     we see at the top of the page. Then under the heading
   5     "ICNARC Case Mix Programme":
   6        "It is recognised that case mix adjustment is
   7     necessary to allow meaningful outcome comparisons. The
   8     ICS audit document recommended collection of patient
   9     physiological data based on the APACHE II for case mix
  10     adjustment. However, with this and other such methods,
  11     there are a number of problems with standardisation of
  12     data collection, especially of physiological data."
  13        That is the problem with the collection in each
  14     unit, not being uniform?
  15   A. Yes, that is correct.
  16   Q. "Similarly, determining the reason for admission can be
  17     problematical since it is not always well described
  18     simply by the admission diagnosis."
  19   A. That is correct.
  20   Q. An example of that would be what?
  21   A. A patient arrives and has low blood pressure and is not
  22     breathing. You have to make a clinical judgment as to
  23     which is the most important reason for admission. Both
  24     will have a severe effect on outcome, so you have to
  25     make a clinical judgment as to the most important,

   1     because you are only allowed one diagnostic category.
   2   Q. So two people in two different units can be presented
   3     with exactly the same patient and make a different call?
   4   A. That is right. That is what ICNARC is about: trying to
   5     standardise that sort of thing.
   6   Q. So picking that up, if we go to the next paragraph:
   7        "These and other problems have been addressed
   8     during the development of the ICNARC Case Mix Programme,
   9     following experience gained from the ICS UK APACHE II
  10     study. Since 1995 [which is right at the tail end of
  11     the Inquiry's period], when the case mix programme
  12     began, data on all admissions to participating units
  13     have been collected using standard rules and
  14     definitions. The ICNARC dataset is shown in
  15     Appendix 2."
  16        I think that is page 67. If you scroll down that
  17     page, and then 68, these are the details that are
  18     collected, are they not?
  19   A. Yes.
  20   Q. And it goes on, 69, Reason for Admission. Then the
  21     worst physiology data in the first 24 hours. Other
  22     conditions, at the foot of the page, which is where we
  23     pick up if there is more than one reason for admission?
  24   A. Correct.
  25   Q. Then 70, Outcome. That is divided into ICU outcome, and

   1     then at the foot of the page, hospital outcome?
   2   A. Yes.
   3   Q. Then 71, scroll down to the heading "Outcomes":
   4        "A record should be kept of major complications of
   5     therapy and critical incidents which occur during the
   6     period of ICU care. Although information on health
   7     status and quality of life at 6 and 12 months after
   8     discharge is desirable, it is not considered feasible to
   9     collect this routinely."
  10        Because it is too big a task?
  11   A. That is correct.
  12   Q. So it is very difficult, even with the well-developed
  13     dataset like this, to look any further down the line
  14     than the immediate weeks post-discharge from the unit or
  15     the hospital?
  16   A. That is correct. I think you could ask why only 132
  17     units are members of ICNARC. The problem is that they
  18     require essentially a fairly dedicated audit clerk,
  19     a fairly senior one, who is not available to even
  20     produce the standard audit data, so chasing patients up
  21     is not going to be a high priority.
  22   Q. If we go back to page 58, please, where we broke off to
  23     go into this Appendix to the report, in the middle of
  24     the page, the paragraph beginning "Audit:
  25        "Audit is an ongoing activity and must be

   1     sustainable. Dedicated staff are required to facilitate
   2     this."
   3        That is the audit staff you are referring to?
   4   A. Yes.
   5   Q. "Help and advice on these matters is obtainable from
   6     ICNARC. Because of the need for standard definitions in
   7     all areas of data collection it is recommended by the
   8     ICS that all units register with the ICNARC Case Mix
   9     Programme. This will allow confidential, independent,
  10     objective audit of clinical practice, and meaningful
  11     assessment of outcomes."
  12        So that would be a relevant assessment of one unit
  13     against another?
  14   A. Yes.
  15   Q. You are suggesting, therefore, that the reason why more
  16     than half the units in the country do not subscribe to
  17     ICNARC is that they will need dedicated qualified staff
  18     to do it, and indeed choose to employ, as it were, an
  19     extra nurse rather than a data clerk?
  20   A. That is right.
  21   Q. Does the Intensive Care Society think that it ought to
  22     be compulsory for all units to subscribe to this type of
  23     audit case mix programme?
  24   A. I think we do, yes.
  25   Q. So far as you are aware, is that a suggestion that the

   1     Department of Health has taken up?
   2   A. It looks like -- well, not as yet. They have promoted
   3     ICNARC, suggested intensive care units join it, but in
   4     the end they have not put their money where their mouth
   5     is.
   6   Q. So if it were to be a requirement, then every unit would
   7     simply have to find the money for that from its budget,
   8     if it was a requirement?
   9   A. That would be the case, and probably something else
  10     would be cut.
  11   Q. Can I go to your witness statement, please, WIT 53/20?
  12     Still dealing with audits and so on, C7. You say:
  13        "How a level of skill is found to be acceptable
  14     and how the likelihood of reaching an acceptable level
  15     of competence in any technique has only recently been
  16     considered in the training of medical staff. Cusum" --
  17     that is cumulative sum, is it not?
  18   A. Yes.
  19   Q. " -- analysis ... is one method. This technique is new
  20     and it is unlikely that any practising consultant would
  21     be aware of this method of assessing whether competence
  22     has been reached. Given the number of operations
  23     involved, cusum analysis might be quite revealing in
  24     establishing competence of the consultants involved."
  25        If we go to ICS 1/106, that is the editorial from

   1     the British Journal of Anaesthesia published in December
   2     1995, which introduced (if that is the right word) the
   3     paper which is at page 108 by Kestin
   4     entitled "A statistical approach to measuring the
   5     competence of anaesthetic trainees at practical
   6     procedures."
   7        Could you just explain to me, Dr Lawler, in so far
   8     as you are able to explain to someone like me, what is
   9     cusum, what is involved in cusum and why it may be an
  10     advance as an analysis and measuring tool on what went
  11     before?
  12   A. I suppose it is a bit like snakes and ladders. You go
  13     up a ladder and then you fall down. Let us consider an
  14     easy operation. If I make a mistake, I fall down a long
  15     way and I am trying to climb back up the hill. It will
  16     take me a long time to climb back up the hill because
  17     I have fallen a long way, because it was an easy
  18     operation.
  19        If it was a difficult operation, I would not fall
  20     very far and it would be quite easy for me to climb back
  21     up the hill.
  22        If we think about the analysis technique as trying
  23     to maintain or gain or remain in the same place against
  24     a game of snakes and ladders, you can get some feel for
  25     what is going on.

   1        Clearly, the problem is working out what is an
   2     acceptable failure rate, mistake rate, complication
   3     rate, following any operation.
   4        If there is a high complication rate expected,
   5     gained from a knowledge of audit of the whole world,
   6     a large area if the expected complication rate is high
   7     we would expect it not to fall too far and climb back up
   8     easily. It is a way of assessing things, a graphical
   9     way of looking at things.
  10   Q. It is a statistical method, is it not, using the
  11     cumulative sum of a clinician's experience of
  12     a particular technique?
  13   A. The clinician's experience, their judgment.
  14   Q. And compares that with a predetermined acceptable
  15     failure rate?
  16   A. That is right.
  17   Q. You can use that, then, to look at an individual's
  18     trends in a graphical way, and you can see -- they can
  19     see themselves -- when they have fallen below the
  20     predetermined acceptable standard?
  21   A. Yes. They have fallen off their ladder.
  22   Q. So it is a tool that can be used not only in the initial
  23     training of people to say "You are now competent to go
  24     out into the world and call yourself a surgeon", it is
  25     a tool that can be used throughout someone's

   1     professional career to chart how they perform
   2     a particular technique?
   3   A. At any stage, not just through training.
   4   Q. And the Inquiry has already received papers, I think,
   5     from Dr Swanton last week, which indicated a paper from
   6     Mr de Leval which dealt with the way in which even a very
   7     experienced, in that case paediatric cardiac surgeon,
   8     can have a string of success followed by an apparently
   9     inexplicable bout of failure for a particular operation?
  10   A. That might actually mean he is still operating within
  11     normal boundaries.
  12   Q. Yes, so if we go, then, to the paper itself, I do not
  13     want to get too bogged down in the detail of it, but if
  14     we go to 108, if we take the left-hand column under the
  15     heading "Summary". Kestin works at the Derriford
  16     Hospital in Plymouth?
  17   A. Correct.
  18   Q. Kestin's paper says, let us start at the beginning:
  19        "Cusum analysis is a statistical technique to
  20     distinguish deviations from an acceptable failure rate.
  21     The progress of anaesthetic trainees learning four
  22     practical procedures ... was monitored from their first
  23     attempt using cusum analysis. Suitable acceptable and
  24     unacceptable failure rates for each procedure were
  25     chosen by consultant anaesthetists."

   1        So the key to the whole of this procedure is,
   2     choose what the baseline is. That is fundamental, is it
   3     not?
   4   A. Absolutely.
   5   Q. In this case, I do not want to put it too crudely when
   6     you suggest that Kestin went round the common room and
   7     said to his colleagues, "What is an acceptable level for
   8     a trainee for X?"
   9   A. I was not there, but it would fit.
  10   Q. We do not want to, as it were, slag off Mr Kestin's
  11     methods when he is not here to answer for himself, but
  12     in something like an operation, say a cardiac operation,
  13     how would one go about establishing the norm which is
  14     necessary before the cusum analysis can be put into
  15     play?
  16   A. You could look at average outcome from a normal
  17     hospital, or a major hospital which does a lot of these
  18     operations.
  19   Q. If you had a system, for example, where, for example,
  20     the Society of Cardiothoracic Surgeons collected data
  21     every year on outcome of cardiac operations in order to
  22     arrive at a complete data set for the entire country,
  23     one could take the average thrown up by those figures
  24     and take those as the baseline for the cusum of someone
  25     else's?

   1   A. You could do. That would probably give you an
   2     acceptable success or failure rate and what might be
   3     called an unacceptable complication rate. The major
   4     problem might be that the case mix of hospital which is
   5     producing those statistics may not be normal, because
   6     the hospitals producing those statistics might well be
   7     hospitals which deal with the complex patient. That
   8     might not give you a fair average.
   9   Q. It is often said by centres who have a bad mortality
  10     rate, for example, for any particular procedure, that,
  11     "Yes, I know our figures are higher than the hospital
  12     next-door, but that is because they send us the
  13     difficult ones and they die on our patch, not on
  14     theirs".
  15   A. That is what is said and it might be true. My intensive
  16     care has a 35 per cent death rate. The reason is
  17     because all the hospitals around send me their difficult
  18     patients. My APACHE outcomes are very good.
  19   Q. So if one married the APACHE system which as it were
  20     screens for case mix, for intensive care at least, and
  21     one would then be able to arrive at an acceptable
  22     benchmark?
  23   A. I think that might be a reasonable way of doing it.
  24   Q. To feed into the cusum analysis?
  25   A. Yes.

   1   Q. Would that work for surgery as well as for intensive
   2     care outcome?
   3   A. I see no reason why it should not.
   4   Q. We see on the right-hand side, halfway down the page:
   5        "For the experienced clinician, the cusum graph is
   6     a continuous audit of quality and a measure of the
   7     effects of any change in technique, for example, using
   8     new equipment or a different anatomical approach."
   9        That would apply to correcting a particular
  10     congenital heart defect in a different way, for example?
  11   A. Yes.
  12   Q. "The cusum analysis can been used to monitor training in
  13     practical procedures..."
  14        It is unnecessary to go through the detail of the
  15     paper.
  16        If we go to the end at 111, the left-hand column,
  17     halfway down the first paragraph in the left-hand
  18     column:
  19        "This principle is used in the objectively
  20     structured clinical examination in the FRCA part 3
  21     examination ... the data required for cusum analysis are
  22     easy to obtain and allow statistical decisions to be
  23     made with reference to minimum acceptable standards.
  24     The disadvantages are that it relies on the honesty of
  25     trainees, their consistent interpretation of the

   1     definitions of success and failure, and does not assess
   2     other important aspects such as safety."
   3        What does that last passage mean, about safety?
   4   A. I do not know, the safety bit.
   5   Q. The next paragraph, missing out the first few lines:
   6        "The acceptable and unacceptable failure rates
   7     used in this study were obtained from a consensus of
   8     consultant anaesthetists in Plymouth. There are other
   9     methods of defining standards, for example, from
  10     a survey of the literature."
  11        That might tell us what the worldwide best
  12     standard was, or the best standard in Australasia or the
  13     United States.
  14        "These standards could be altered to suit the
  15     patient population ... or altered according to the
  16     experience of the trainee. If training is shorter, it
  17     may be impossible to provide sufficient experience of
  18     these procedures to demonstrate statistically acceptable
  19     success rates. It would be important to know the
  20     failure rates of experienced practitioners if national
  21     standards are to be specified for structured training.
  22     This information is lacking, but should not be difficult
  23     to obtain."
  24        That would apply in principle to surgical
  25     techniques in any discipline?

   1   A. The technique is not a medical technique. This was
   2     introduced as standard quality control in industry, and
   3     has been applied to this, so I see no reason why it
   4     could not be applied to cardiac surgery.
   5   Q. So this is already a derivative application of the
   6     statistical technique.
   7        I want to deal with just a couple more topics.
   8     One of those is the location of intensive care units.
   9     In the 1997 standards, at ICS 1/12 under the heading
  10      "Siting", the fourth paragraph:
  11        "Careful siting of departments can help to
  12     minimise the distances patients are moved. Where there
  13     is a lot of patient flow, large lifts and extra-wide
  14     corridors are mandatory."
  15        Then the next paragraph suggests that you have to
  16     look to see where your ICU is compared with access to
  17     the hospital; for example, easy for ambulances to bring
  18     very sick patients and so on.
  19        What about the position of the intensive care unit
  20     in relation to the operating theatres where there is
  21     a lot of elective surgery going on? What should the
  22     position be there?
  23   A. One has to look at the actual hospital itself. Once
  24     upon a time it was stated quite clearly that the
  25     intensive care unit should be next-door to the operating

   1     theatre. That is not so obvious these days.
   2        Certainly, if there is a lot of elective surgery
   3     going on, you want it fairly close.
   4   Q. Why is it not quite so important to have it next-door
   5     any more?
   6   A. Because there are other perhaps more important
   7     adjacencies. Perhaps it is more important for the
   8     intensive care unit to be next-door to the imaging
   9     department. If you have a relatively low patient
  10     throughput, it may be more important that you can take
  11     your patient to the imaging department than the
  12     operating theatre. If you do not use the imaging
  13     department very much, you do not need to take them
  14     there. If you have a high surgical throughput,
  15     a thousand patients a year, let us say, which is
  16     a standard expected throughput for a cardiac surgical
  17     unit, very few of those will need imaging. The
  18     adjacency will be to theatres. For me, I am talking
  19     about me, I have 350 patients a year, one of my units
  20     needs to be next door to the CT scanner because it deals
  21     with neurosurgery, and that is more important than being
  22     next door to the neurosurgical theatres. So it is your
  23     clinical need for adjacency.
  24   Q. If you had a Cardiac Intensive Care Unit --
  25   A. -- you want to be next door to the theatre.

   1   Q. You would want a specialist unit dealing with cardiac
   2     patients to be next to the theatre?
   3   A. That would probably be the better adjacency.
   4   Q. In a children's hospital dealing with the range of
   5     children's medicine, to a specialist paediatric
   6     intensive care unit but not only dealing with cardiac
   7     patients, what about that?
   8   A. That it starts to get complicated. I cannot say because
   9     I do not know where the patients are coming from. It
  10     may be that they need to be next-door to a door because
  11     most of the patients may actually be coming from outside
  12     the hospital rather than their own operating theatre.
  13     It will depend upon the case mix of the individual
  14     intensive care unit.
  15   Q. Now I want to deal with training and standards, and
  16     accreditation and enforcement of standards and so on.
  17     Just before I do that, I want to deal with facilities
  18     for relatives and relatives of patients.
  19        If we go to the 1984 standards from the Intensive
  20     Care Society, ICS 1/145, two-thirds of the way down the
  21     page:
  22        "1.4.15, Relatives' Rooms: waiting areas (minimum
  23     of two) adjacent to the reception area, including one of
  24     10 square metres suitable for interviews and one of 20
  25     square metres with drinks dispenser, radio, TV aerial

   1     socket", and other things that were "mod cons" in the
   2     1980s.
   3        If we go to the 1987 standard to see how that has
   4     developed, if at all, at the time, page 22, ICS 1/22,
   5     the last paragraph:
   6        "At least two waiting areas are needed. They
   7     should be adjacent to the reception area and include one
   8     of 10 square metres suitable for interviews including
   9     the breaking of bad news and bereavement counselling [so
  10     that has been added] and one of 20 square metres", with
  11     the same facilities.
  12        Then this:
  13        "The position of the relatives' room must prevent
  14     relatives from having continuous access to staff..."
  15        That is because the staff are busy with patients,
  16     presumably?
  17   A. No. Because it is really about separating the entry of
  18     the laughing and joking staff as they come on duty or
  19     leave from grieving relatives who want two separate
  20     entries, because you do not want them to walk past the
  21     door.
  22   Q. It is not so much stopping them having access to the
  23     staff working, it is better to stop them having access
  24     to staff not working?
  25   A. That is right.

   1   Q. "Siting should also prevent relatives from overhearing
   2     staff conversation, whether it is related to patients or
   3     personal issues. Items of value ..."
   4        Is it, in your experience, the norm that there is
   5     a room suitable for interviews in which bad news is
   6     broken to relatives of intensive care patients?
   7   A. It is the norm in general intensive care units. It is
   8     not the norm to have two waiting areas. The health
   9     building note, in other words, the NHS building note,
  10     does not suggest you have two waiting areas. The
  11     waiting areas suggested by the NHS building notes are
  12     considerably less than that, despite the fact that the
  13     unit may be very big.
  14        So the builders and the hospital administration
  15     may choose to limit the amount of space devoted to
  16     relatives' care.
  17   Q. So the room of 10 square metres is not a very big area.
  18     Is there a generalisation we can make about who breaks
  19     bad news to relatives of patients in intensive care
  20     units, whether it is a physician or a nurse or
  21     a surgeon?
  22   A. I think the initial information about a deterioration in
  23     the patient's condition will often come from a senior
  24     nurse on a unit, and that will be followed up by
  25     a doctor, often the consultant or someone fairly senior

   1     on that consultant's team. It may be the intensive care
   2     doctor, the intensive care consultant or it may be the
   3     admitting consultant, in this case the cardiac surgeon.
   4        The reason why the nurse may open the conversation
   5     is because those two doctors, the intensive care doctor
   6     or the cardiothoracic surgeon, are better employed
   7     trying to save the patient's life, and quite frankly,
   8     I would rather the cardiothoracic surgeon looked after
   9     my child than looked after me, if it was my child's
  10     life. That is the practical reason why bad news is
  11     often broken by, or beginning to be broken by, the
  12     nurses.
  13   Q. There may be cases where the relatives, as it were,
  14     tease out of the nurse the fact that the news really is
  15     bad: "Are you saying my husband is going to die?", that
  16     sort of thing. But in principle, should the final bad
  17     news, if there is such, be broken by the surgeon, if it
  18     is a theatre case?
  19   A. I believe it should be, although quite often doctors are
  20     not very good at breaking bad news; their training in
  21     bereavement counselling, or counselling, is nothing like
  22     that of nursing staff and usually doctors are very bad
  23     at it -- not so much if they are involved, but it is
  24     a mistake as far as they are concerned. "Mistake" is
  25     the wrong word. They regard it as a failure when their

   1     patient dies.
   2   Q. What about the role in your intensive care unit, if that
   3     is appropriate, the role on the intensive care unit of
   4     support staff or counselling staff there for relatives,
   5     or, in our case, parents, as opposed to nurses, thinking
   6     of social workers or qualified counsellors. What role
   7     would they have in this process?
   8   A. If a patient is deteriorating, the nurse looking after
   9     the patient will usually go and discuss or let the
  10     relatives know what is going on. If the patient
  11     deteriorates and dies, that nurse will then follow that
  12     up. Often the relatives are present at the death. The
  13     doctor will then come with that nurse and tell the
  14     relatives what has happened, often in some detail.
  15        The follow-up, particularly if patients die, for
  16     us and in many places, is done by telephone calls, or
  17     the relatives are given some documentation which
  18     suggests (for us and many units now) that they ring up
  19     the units, make an appointment, discuss what has
  20     happened, usually with a nurse or a bereavement
  21     counsellor -- many nurses have had bereavement
  22     counselling -- and run through the nursing system.
  23   Q. That would come how often? How soon after the death of
  24     the relative?
  25   A. They can ring up any time they like, but usually this

   1     will happen in a couple of weeks. We have a pamphlet
   2     which gives the phone numbers, "Ring up at such-and-such
   3     time, make an appointment". Many units have got that
   4     far. What units do not have is some very formalised
   5     post-death or whatever meeting. The formalisation is
   6     not there. It is very ad hoc. It is very
   7     patient-orientated.
   8   Q. Is it normal for the surgeon who, in the surgeon's
   9     language, has 'lost' the patient, to invite the
  10     relatives or parents of the child to come and see him or
  11     her to discuss matters?
  12   A. There is no follow-up clinic in that format, no.
  13   Q. But it would be a good thing if there was?
  14   A. It would be a good thing if there was.
  15   Q. Let us look at training and standards then. If we go to
  16     your witness statement, WIT 53/10, please, you deal in
  17     that page and the following pages with training for
  18     intensive care:
  19        "Until 1983 [in the UK] there was no formal
  20     specialist training in intensive care medicine, at
  21     either adult or paediatric level. Training was
  22     undertaken within the parent specialty (usually
  23     anaesthesia) as one of its many modules."
  24        Then you say that even today training
  25     opportunities are limited, and you mention the process

   1     of Calmanisation, which you discussed this morning.
   2        "In 1983, the Department of Health and Social
   3     Security funded 12 JACIT (Joint Accreditation Committee
   4     in Intensive Therapy) posts ..."
   5        You explain why they were not a success.
   6        Paragraph 3.3:
   7        "In 1992, recognising the problems of providing
   8     consultants in adult intensive care, presidents of the
   9     Royal College of Anaesthetists, Physicians (which
  10     included paediatrics) and Surgeons established a new
  11     Committee, the Intercollegiate Committee for Intensive
  12     Therapy."
  13        You explain the remit was to devise an effective
  14     package of training for intensive care to be undertaken
  15     within the normal base specialty training programme.
  16        That was for three years, and then there was
  17     another committee under Professor Hatch at Great Ormond
  18     Street, setting up a programme for paediatric intensive
  19     care.
  20        So it is only at the very end of the Inquiry's
  21     field, 1992 through to 1995, that these committees are
  22     being established really for the first time to set out
  23     a formal training process in the specialty of intensive
  24     care; is that right?
  25   A. That is correct, although, if we go back to the JACIT

   1     posts, at the stage where you could become a consultant,
   2     there was a training package put together, but it was at
   3     the point where you already could be a consultant.
   4   Q. So you had been through JACIT by that stage?
   5   A. Yes.
   6   Q. The trouble was --
   7   A. If you could be a consultant, why be a trainee for
   8     another two years when you could get a job just as well?
   9   Q. I see that. That is the point you made.
  10        The Intercollegiate Board for Training and
  11     Intensive Care Medicine: that only came on the scene in
  12     its current form in 1996. It was a reconstitution of
  13     the Intercollegiate Committee for Intensive Therapy?
  14   A. That is correct.
  15   Q. As you say in paragraph 3.4, the idea was that training
  16     was to be undertaken in accredited units, with an
  17     educational package of specified content to be obtained
  18     at three levels, Senior House Officer and at two levels
  19     at Specialist Registrar."
  20        Accredited by whom?
  21   A. The Intercollegiate Board.
  22   Q. So the Intercollegiate Board would say to a unit, "You
  23     have passed muster to become a training centre"?
  24   A. Correct.
  25   Q. Presumably in order to become a training centre, the

   1     centre had to have reached certain minimum standards of
   2     equipment and so on?
   3   A. We are in the process of change as we speak. When the
   4     Intercollegiate Board put its act together, it did this
   5     very much on paper, without actually assessing any
   6     particular training package. The initial method was
   7     requiring those intensive care units to have some
   8     facilities, which was a method of improvement of the
   9     availability of intensive care. For instance, you
  10     cannot be a training unit unless you have several
  11     consultant sessions, with the consultants available for
  12     nothing else other than intensive care. That
  13     potentially had teeth, because if there were not
  14     separate sessions you could have a trainee. You had to
  15     have an adequate number of nursing staff and an adequate
  16     throughput of patients. Without that, you could not be
  17     considered to be a training unit. On paper, if you
  18     delivered that, you were allowed interim approval for
  19     training. In the last six to eight months, units which
  20     may be training are in the process of being assessed for
  21     training. I think Bristol is actually assessed
  22     tomorrow, as about being an acceptable unit for
  23     training.
  24   Q. So the Intercollegiate Board will send its
  25     representatives down?

   1   A. Yes, to look at the training package they have put
   2     together.
   3   Q. So they are looking at the physical surroundings?
   4   A. The physical surroundings can largely be done on paper,
   5     but they want to talk to the trainers and some of the
   6     people actually in post to find out what the trainers
   7     say, or what the trainers are getting is the same, and
   8     quite often what the trainees say is not quite the same
   9     as the trainers say.
  10   Q. So the idea is that for the long-term survival of
  11     a specialist unit that would be of sufficient size to be
  12     a training unit, keeping this accreditation as
  13     a training unit is going to be very important for its
  14     future development?
  15   A. It will be, assuming you want to have trainees.
  16   Q. Just go to the foot of page 11. This Intercollegiate
  17     Board is set up. When it started to do its thinking,
  18     the Calman training proposals had not been implemented;
  19     is that right?
  20   A. Yes.
  21   Q. So it was originally operating on the basis that there
  22     would be a longer training period than is now the case?
  23   A. Yes; very much so.
  24   Q. So the initial idea was that two years out of Specialist
  25     Registrar training could be taken up by intensivist

   1     training?
   2   A. That is correct.
   3   Q. Two years out of how many?
   4   A. Essentially six.
   5   Q. Now what is the setting?
   6   A. Two out of four. Intensive care has not allowed itself
   7     to be diluted, because it is the view of the
   8     Intercollegiate Board that the quantity of intensive
   9     care training, even at two years, is only just adequate,
  10     and if we reduced it pro rata with the reduction in the
  11     Calman training for its parent specialties, there would
  12     be insufficient experience in intensive care to produce
  13     reasonably trained consultants.
  14   Q. If we go to ICS 1/44, the bottom of the page, this is
  15     a 1997 Standards document:
  16        "Consultants in intensive care medicine need to be
  17     specialists in all aspects of acute medicine and
  18     resuscitation in the broadest sense ...
  19         "In future, consultants with sessions in the
  20     ICU ... will be expected to have undertaken at least one
  21     year's training in intensive care medicine. Full-time
  22     consultants in intensive care medicine and/or directors
  23     of ICUs will be expected to hold a postgraduate Diploma
  24     in intensive care medicine, as well as their primary
  25     post-graduate qualification. It is envisaged that

   1     a CCST (Certificate of Completion of Specialist
   2     Training) will be awarded at the completion of training.
   3         "It is proposed that post-graduate training in
   4     intensive care medicine is undertaken at three
   5     levels ..."
   6        Is this pre or post the Calman training scheme?
   7   A. This was set up pre; we have maintained it post. The
   8     difference, if you see there are three levels, basic
   9     intermediate and higher. You could look at that at
  10     pre-Calman, SHO, Registrar and Senior Registrar. Now
  11     you look at it as basic, which is SHO, intermediate and
  12     higher, as being two chunks within the specialist
  13     registrar period, so we try to keep it.
  14   Q. If I were to be on my way to qualifying to be
  15     a consultant intensivist, the four years leading up to
  16     reaching that level would involve this specialist
  17     training taking up two of those four years?
  18   A. The intermediate and the higher, yes, that is two years,
  19     plus three months as basic, as SHO.
  20   Q. And the rest of my time I would spend ...
  21   A. Doing anaesthesia or medicine, or surgery, or whatever.
  22   Q. That is the broad remit, then, for the board, the
  23     Intercollegiate Board. Back to your witness statement,
  24     please, at WIT 53/12.
  25        The board set up a Diploma in Intensive Care

   1     Medicine. This is what, for adult intensive care
   2     medicine?
   3   A. Yes.
   4   Q. We will be dealing with it in a moment. We see from the
   5     middle of the paragraph that you are the Chairman of the
   6     Examiners?
   7   A. Yes.
   8   Q. So what happens? How is this assessment carried out?
   9   A. I am sorry, would you explain the question?
  10   Q. To get a diploma?
  11   A. To get a diploma you have to have another qualification
  12     membership, Royal College of Physicians, a primary
  13     qualification in one other specialty, and then you have
  14     to complete a logbook. In other words, you have to have
  15     shown you have been present in intensive care for
  16     a reasonable period of time. You have to have been
  17     assessed by your educational supervisor as being
  18     acceptable. The exam is then in five chunks:
  19     a dissertation (a long essay), the presentation of the
  20     logbook on which you are examined in two sets, and then
  21     two vivas.
  22        To get that exam, the eligibility requires -- and
  23     I am talking about eligibility -- that you have done one
  24     year's training in intensive care medicine. That allows
  25     you to be eligible. It is unlikely, if you are just

   1     eligible, you will pass that exam.
   2        The eligibility was to allow trainees who had not
   3     done the prescribed training in intensive care medicine
   4     to take that exam. The board is very difficult about
   5     allowing equivalence training. It is very specific: you
   6     will do three months intensive care training as an HSO.
   7     If you do 12 months training as an HSO, even though it
   8     is the same job done in the same unit as a Specialist
   9     Registrar, you will not be allowed to carry that through
  10     as Registrar training, even though what you are doing is
  11     the same.
  12        But it might make you eligible to take the exam.
  13     The problem is, it is my view, and certainly some of my
  14     colleagues' views, that the exposure and training in
  15     intensive care is insufficient within the two years that
  16     we have set. By making it difficult to take the exam
  17     and so on, we might raise the standard. That is a very
  18     hard view and not all my colleagues agree with me.
  19   Q. There is not yet an example of paediatric intensive
  20     care, but it is suggested at paragraph 3.7 that there
  21     might be. It is implicit in that paragraph, that
  22     paediatric intensive care is now as a result of the
  23     Geldart incident, the subsequent framework for the
  24     future report, perhaps in a better funding position from
  25     the Department of Health than it was before that?

   1   A. Considerably better.
   2   Q. Again, as we see at 3.8, none of these training packages
   3     were available before 1996?
   4   A. Not for trainees, although, as I said, the JACIT posts
   5     were available for people who had completed their
   6     training already.
   7   Q. We have looked at the accreditation of the training
   8     centre and the training that the trainee has to go
   9     through, and the Diploma that the trainee can in due
  10     course apply for.
  11        Once somebody has jumped through all of those
  12     things and become a consultant, intensivist, they are
  13     accredited by their Royal College?
  14   A. There is no CCST as such as yet in intensive care. That
  15     is not available until June of this year.
  16   Q. But somebody with, let us say, an anaesthesia background
  17     is accredited by their Royal College?
  18   A. Not to do intensive care only anaesthesia.
  19   Q. Let us look at the time once the CCST is available.
  20     Once the hypothetical trainee has become a consultant
  21     intensivist, they will become accredited as an
  22     intensivist?
  23   A. Correct.
  24   Q. How is that accreditation lost, in normal circumstances?
  25   A. I do not know. As far as I know, no-one has ever lost

   1     a CCST because CCSTs have only just appeared, so I do
   2     not know what will happen. I know why they will lose
   3     their accreditation, but I do not know what will
   4     happen. They will lose it presumably because they fail
   5     at a clinical level.
   6   Q. Under the continuing education programme?
   7   A. That is correct, but no-one has worked out exactly what
   8     to do yet.
   9   Q. Intensivists are a bad example because they have never
  10     been accredited as intensivists, but hitherto, what has
  11     one to do to persuade the Royal College to take away
  12     one's accreditation?
  13   A. The Royal College could not. The GMC could strike you
  14     off, but the Royal Colleges could not do very much at
  15     all.
  16   Q. So you are accredited by the Royal College?
  17   A. Being an anaesthetist, but I am also a doctor and I can
  18     give anaesthetics.
  19   Q. So what the Royal College giveth, it could not take
  20     away?
  21   A. The only teeth the Royal College has, until I think
  22     probably the future, is to alter the environment in
  23     which you work. If I am working in a large hospital
  24     I usually use trainees as workhorses -- we have
  25     mentioned this before. The Royal College can make it

   1     difficult for that group, hospital, to employ trainees.
   2     So because I am a bad doctor, that is as far as they can
   3     go. If the hospital does not have any trainees, the
   4     college has no teeth. As a single-handed doctor, the
   5     college cannot do anything to him.
   6   Q. So the weapons that exist against the individual
   7     hypothetical failing doctor are ultimately --
   8   A. Marginal.
   9   Q. The nuclear weapon is the GMC?
  10   A. The nuclear weapon is the GMC. The nuclear weapon is
  11     not the colleges. The colleges can alter the
  12     environment of work. For example, if we are in Bristol,
  13     which is where we are, the Royal College of
  14     Anaesthetists could stop trainees being trained in
  15     Bristol. That would have, at the moment, an effect upon
  16     workload, because the trainees do a lot of work. If the
  17     trainees no longer have a service commitment, taking the
  18     trainees away might have no effect on the Department's
  19     ability to turn over patients.
  20   MR MACLEAN: Would you give me one moment, Dr Lawler?
  21     (Pause).
  22        Does the Panel have any questions for Dr Lawler?
  23   THE CHAIRMAN: We have no questions.
  24   MR MACLEAN: Dr Lawler, in those circumstances, could
  25     I thank you very much indeed for coming to give this

   1     evidence? If, as we say to all the witnesses, there is
   2     anything that you have omitted or anything you would
   3     like to give us any further detail on, do so now, if you
   4     wish. Failing that, if you think of anything on the way
   5     home, you can submit further statements to us in
   6     writing. We will be here, to use the Chairman's phrase,
   7     for "some time", so feel free to contact us in the
   8     future. Unless there is anything you want to add now,
   9     I think that is it, thank you very much.
  10   THE WITNESS: Might I make a comment? Cusum analysis has
  11     come up twice, I know now. I decided the look at this
  12     yesterday, to look at what we might call acceptable and
  13     unacceptable outcomes and how to assess performance --
  14     I asked my daughter to do the mathematics and she found
  15     there was a mistake in the paper. It did raise some
  16     very interesting findings. It is very clear that to
  17     look at outcome of a procedure, it is important to know
  18     what is an acceptable or an unacceptable outcome, and
  19     some of the figures that she produced -- and they are
  20     clearly open to check -- made me quite surprised.
  21        For instance, if an acceptable death rate was 1 in
  22     3, 33 per cent, and I think that has been raised, four
  23     consecutive operations on the trot producing a good
  24     outcome suggests that that is more than acceptable.
  25     On the other hand, three consecutive deaths does not

   1     suggest that the outcome is poor. Clearly, I think you
   2     might require a statistician to look at this. I think
   3     these are extremely important observations. I will
   4     check my daughter's mathematics, because as I said, she
   5     did find a mistake in that paper.
   6        It came as a surprise to me, sir.
   7   MR MACLEAN: Dr Lawler, I am sorry, it is my fault. There
   8     is one other matter I should have raised.
   9        You will know that much of the media focus on
  10     Bristol and the events at the Bristol Royal Infirmary
  11     has focused on paediatric cardiac surgeons. This
  12     Inquiry goes much more widely than simply an
  13     investigation into paediatric cardiac surgery.
  14        Is there any particular aspect of the care of
  15     paediatric cardiac surgical patients which, from your
  16     particular field of expertise as an intensivist, the
  17     Inquiry ought to be looking at when asking itself
  18     whether or not the performance of the cardiac services
  19     in Bristol was as good as it ought to have been?
  20   A. I think it is a problem for a team. It is not
  21     necessarily the cardiac surgeon, it is the whole team
  22     beginning from the staff right through to the finish.
  23     I think I mentioned earlier on, although I know my
  24     intensive care unit has an extremely good short term
  25     outcome, I also know, as I mentioned, that if

   1     I discharge patients early, their death rate increases.
   2     I know that personally. I also mention that there
   3     appears to be a publication that is going to say that.
   4     Outcome is dependent on a team. There may be a weak
   5     link and we do not know where it is.
   6   Q. You are an intensivist but by background an
   7     anaesthetist?
   8   A. Yes.
   9   Q. The Inquiry will look at the events in the operating
  10     field and outside. Are there any particular matters in
  11     respect of either anaesthesia or intensivists,
  12     consultancy, that the Panel ought to be -- are there any
  13     tell-tale signs that set the bell ringing in the head?
  14   A. I said earlier on that it appears to be good outcomes --
  15     good outcomes appear to be associated with teamwork.
  16     I did mention "toys for the boys", but also the fact
  17     that outcomes seem to be associated with a clinical
  18     director who had a lot of control, a senior nurse who
  19     had a lot of control -- I think I mentioned protocols
  20     and guidelines. I am not sure if I did mention that,
  21     but I certainly mentioned low staff turnover as being
  22     very important aspects of outcome, rather than the
  23     particular skill of any individual or, as I said, the
  24     quality and quantity of the available equipment.
  25        I think that is certainly the key in adult

   1     intensive care, and it is certainly pretty obvious in
   2     the UK, that semi-closed units tend to be able to
   3     produce a system which leads to better outcome.
   4   MR MACLEAN: Thank you very much, Dr Lawler.
   5   THE CHAIRMAN: Dr Lawler, the Panel is particularly grateful
   6     to you for those last views and we will obviously be
   7     taking them. As regards your comments on data, I would
   8     seek to assure you we are currently carrying out as
   9     careful an analysis of the data as we can, and take your
  10     comments to heart.
  11        I echo what Mr Maclean said. If there are other
  12     things you would wish to submit to us in writing, please
  13     feel free to do so. We will be here for some time, and
  14     will be happy to hear from you, but for today, I can
  15     only say on behalf of the Panel, thank you very much for
  16     coming to talk to us and to help us.
  17   MR LANGSTAFF: Sir, that concludes the witness evidence for
  18     today. As you will already know, tomorrow we have the
  19     benefit of hearing from Professor Alberti of the Royal
  20     College of Physicians, and we also have two witnesses
  21     who will speak to the paper for the English National
  22     Board.
  23   THE CHAIRMAN: Thank you, Mr Langstaff. 9.30 tomorrow
  24     morning, thank you.
  25   (3.15 pm)

   1     (Adjourned until 9.30 am on Tuesday, 30th March 1999)
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   1
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   3                I N D E X
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   5     DR SUSAN E.F. JONES (Sworn) ... ... ... ... 1
   6
   7     Examined by MISS GREY  ... ... ... ... ... 1
   8     Examined by THE PANEL  ... ... ... ... ... 67
   9
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  11     DR PAUL LAWLER (Sworn) ... ... ... ... ... 70
  12
  13     Examined by MR MACLEAN ... ... ... ... ... 70
  

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Published by the Bristol Royal Infirmary Inquiry, July 2001
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