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Daily transcripts
Hearing summary
10th May 1999
The oral hearings resumed today with evidence from the Royal College of Anaesthetists
(RCA), represented by their President, Professor Leo Strunin. He explained the function of
the RCA and its role in supporting the practice of anaesthesia in Britain. He emphasised
the changes that have occurred in the past five years in relation to training and
re-training, particularly with the introduction of Continuous Medical Education (CME) and
Clinical Professional Development (CPD). He outlined the arrangements for standard
setting, clinical training, accreditation of hospitals for medical training and the
College’s role in the appointment of anaesthetists to consultant positions. He stated
that there have been shortages in fully trained anaesthetists applying for consultant
posts and expressed the RCA’s aim to maintain interview shortlists wholly consisting
of fully trained staff. Professor Strunin confirmed that representatives from the RCA
visit hospitals on a five yearly basis to assess whether the training needs of
anaesthetists were being fully met. He agreed to forward notes relating to visits made to
the Bristol Royal Infirmary during 1984-1995 to the Inquiry team. When questioned about
monitoring the performance of clinical staff, he stated that unless the issue related to
training issues, it would not be the responsibility of the RCA. In the first instance
concerns about clinical competence should be the responsibility of Trusts and if issues
could not be resolved at local level, the General Medical Council (GMC) should become
involved.
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FULL TRANSCRIPT
1 Day 14, 10th May 1999
2 (11.10 am)
3 MISS GREY: Good morning, Chairman. Good morning, Panel.
4 THE CHAIRMAN: I apologise for the fact we are 10 minutes
5 late, but it was a matter of making sure everybody who
6 arrived was organised. Let us begin.
7 MISS GREY: As you know, we have Professor Leo Strunin here
8 this morning, from the Royal College of Anaesthetists.
9 If I could ask him to come forward, please.
10 Professor Strunin, it has been explained to you
11 that we take evidence on oath in the Inquiry, so could
12 I invite to you stand before taking the oath?
13 PROFESSOR LEO STRUNIN (Sworn)
14 Examined by MISS GREY:
15 MISS GREY: Professor, you have in front of you a microphone
16 which should not be too intrusive. You can probably
17 push it back a little bit. If there are any
18 difficulties in hearing you we will indicate this, but
19 you may need to speak up just a little bit and also to
20 go a little slowly for the benefit of the transcript and
21 the stenographers.
22 I know you have in front of you also the documents
23 and statements which you have kindly provided to the
24 Inquiry. You have, too, a computer screen which I hope
25 should in fact be flashing up any relevant documents, so
0001
1 you can use one or the other as you please.
2 If I could ask that screen to show WIT 65/1. That
3 should be the covering page of your statement to the
4 Inquiry, and we have there the author of the statement;
5 that is yourself, is it?
6 A. That is correct.
7 Q. Setting out your qualifications. Then, if we turn to
8 page 21 of the statement and scroll down to the bottom,
9 it has not in fact been signed in the copy that we have,
10 but nevertheless it is your statement. The contents are
11 true; is that right?
12 A. That is correct.
13 Q. And you have come here prepared to speak to it?
14 A. I have.
15 Q. If we could take it back then, please, to page 1 of the
16 statement, the introduction to the work of the Royal
17 College of Anaesthetists. If you can scroll through
18 that, please. Perhaps assisting the Inquiry by setting
19 out the very breadth of the services provided by
20 anaesthetists; is that right?
21 A. That is correct.
22 Q. Over the page, on page 2, if we could see that, please,
23 paragraph (c), you say there:
24 "The circumstances in which anaesthetists practice
25 in the National Health Service have changed out of all
0002
1 recognition", and we are talking about the contrast
2 between the present day and 1984.
3 Would you like to help us by summarising those
4 changes that you think you have seen over those years?
5 A. I should say that between 1984 and 1990 I was not
6 actually in the country, I was in Canada, so what I am
7 telling you is hearsay in that sense, but I have been
8 back since 1990. I did notice the change when I came
9 back in 1990, so in that sense I am aware of it.
10 I think, in a way, the practice of anaesthesia has
11 changed from individual practice. There was quite
12 a well-developed training programme, not very carefully
13 defined in start and finish and length, but there was
14 a good programme. But after that, I think most
15 consultant anaesthetists assumed they were individual
16 practitioners, there was not much corporate identity in
17 terms of departmental structures of keeping up to date,
18 all those things, although people tried to practice as
19 well as they could and the changes that have occurred,
20 of course there, is that there is now much more of
21 a corporate structure.
22 I think most anaesthetists recognise that they are
23 part of the Department, and certainly the Trusts
24 recognise that. They see the Department of Anaesthesia
25 as very, very important in providing acute services and
0003
1 that was why in my statement I indicated what came out
2 of the Audit Commission, who made this point. They
3 believe that they are part of the Department and it is
4 very important that they maintain standards and kept up
5 to date, and so forth, and also those departments that
6 are involved in the training programmes that they now
7 carry out their training programme as the College would
8 wish, and they see that as an important function.
9 So those changes which have moved in a way, if you
10 like, from being an amateur to a professional have come
11 on very quickly, particularly in the last few years.
12 Q. You are emphasising there, I think, two things: firstly,
13 the development of a team or corporate identity and,
14 secondly, more self-consciousness about professional
15 standards and the need to keep abreast of those. Is
16 that fair comment?
17 A. I think that is true. I do not think it is true in
18 anaesthesia, although anaesthetists are better in some
19 respects. They work in departments with some other
20 specialties because of the nature of the work we do, but
21 I think it was fairly common back ten years when people
22 thought, "Well, as long as I am doing a good job it is
23 not actually my problem what is occurring around me",
24 whereas now that has changed and people believe there is
25 a corporate structure and they are responsible for
0004
1 everybody. That is obviously in line with what the
2 General Medical Council now recommends to doctors, that
3 we are not only responsible for our own activities but
4 for those of others around us.
5 Q. If you say that back in 1984 the practice of anaesthesia
6 can be characterised as rather more amateur, what do you
7 have in mind by that?
8 A. It is perhaps an unfortunate choice of words in that
9 sense. I think people saw themselves as individual
10 practitioners, they were keen to develop their own
11 practices, but there was not so much of a corporate
12 identity as there is now. And, of course, in 1984 a lot
13 of specialised things which many anaesthetists take for
14 granted now were really only in their infancy and only
15 just beginning.
16 The obvious ones of relevance to this Inquiry are
17 the changes in intensive care medicine, complex surgery,
18 and so forth, which were all under way in various parts
19 of the system. We are just gradually coming together
20 and people recognise that if you are going to do it
21 well, you have to have a different way of doing it.
22 Q. I think, Professor Strunin, if it helps, you may need to
23 try and speak just a little more slowly and speak up
24 a little, for the benefit of the transcript.
25 If we might come back to some of those things and
0005
1 start perhaps looking at the role of the Royal College
2 of Anaesthetists. In developing those standards you
3 have referred to in those introductory remarks, I have
4 identified a number of means that the College uses for
5 its work in standards setting arising from your
6 statement.
7 The first, if we could look at page 9 of the
8 statement, has at least four strands to it and it is set
9 out at paragraph 6.1. You talk there of the conduct of
10 the fellowship examination, setting standards for the
11 duration and content of training, assessing hospitals
12 for recognition of training and through continuing
13 medical education.
14 You also talk, and I am looking at page 16 of your
15 statement, if we could have that, at paragraph 7.1, of
16 a wider educational role. Paragraph 7.2 talks about the
17 educational programme run by the College, and that would
18 include, would it not, the work of the College in
19 fostering professional research into matters such as
20 audit or aspects of anaesthetic practice. You are
21 nodding, but the nod does not go down on the transcript,
22 whereas a "yes" does.
23 A. I am sorry. That is correct. It might be just as well
24 it does not go down. I said that quickly, so you would
25 not be able to record that bit!
0006
1 Q. Finally, page 17, paragraph 7.8, towards the bottom of
2 the page, you also talk about the role of the RCA in
3 providing assessors to sit on the appointment committees
4 for the appointment of consultant and non-consultant
5 career grade doctors.
6 Would those three different elements -- and of
7 course the first that we looked at, paragraph 6.1,
8 comprised a number of strands -- summarise the main work
9 of the College in setting and regulating standards?
10 A. Yes. I think we are also engaged on some new things
11 now, but that was, certainly for the period from 1984
12 onwards, completely correct, although it would be fair
13 to say that much of the emphasis there was on training,
14 in that the College's sanctions against non-trainees are
15 limited. I think that is true for all the colleges.
16 Q. For the sake of completeness, if I have not mentioned
17 -- new functions of the College?
18 A. I think the two new things I would like to draw the
19 Inquiry's attention to are that, following on from our
20 Good Practice Guide which is in the statement, we are
21 now engaged on a programme of looking at how we can
22 deliver revalidation in line with what the General
23 Medical Council wants to do specifically for
24 anaesthetists.
25 The second thing we are doing is that the
0007
1 Specialist Training Authority, which regulates now all
2 the training programmes, allowed us to extend our SpR
3 training from 4 years to 5 as from 1st August of this
4 year, but on the understanding that we would change in
5 the next 18 months to a competency based training
6 programme. At the moment, like everybody else, we have
7 a time-based programme and that, of course, is in line
8 with the European directives and European specialist
9 medical qualifications order, but the Specialist
10 Training Authority now is keen that all training
11 programmes have a competency base to them, and we just
12 happened to be first to ask for an extension.
13 So that is currently under way, those two things.
14 Q. Could you just move the microphone?
15 Your statement deals, then -- page 6, please, at
16 paragraph 4.3 -- with what one might loosely dub the
17 "regulatory role" of the Royal College of
18 Anaesthetists, but you make the point there, and it is
19 a real one, that that role is a voluntary one and that
20 the two formal sources of control over practitioners
21 are, firstly, the GMC and, secondly, the employer or
22 perhaps Hospital Trust, of an anaesthetist.
23 Would you like to help us as to the relative
24 importance of those three channels of control, or
25 influence, over a practitioner?
0008
1 A. I would like to think that the College's role, even
2 though it is voluntary, people take it seriously, and
3 I think they do. We meet, of course, on a regular basis
4 with anaesthetic departments, the Clinical Director of
5 the Department and the Chief Executive and other
6 officers of the Trust when we do a training visit.
7 Now, although we are looking at training issues
8 there, I think it becomes clear that where there are
9 issues to do with delivery of clinical service we would
10 make more than a note of that, we would say, "It is
11 going to be difficult for you to provide good training
12 if there are problems with the clinical service". So
13 the two are related in that sense, although we have no
14 direct sanctions over clinical activity.
15 We certainly feel that the role of the Department
16 Director and Clinical Director is very clearly defined
17 now, and that individual is responsible for all the
18 clinical activities within the department.
19 Q. So you are talking there about the Clinical Director of
20 Anaesthetic Services?
21 A. Yes, who may or may not be an anaesthetist, it varies
22 from Trust to Trust, but there is always an
23 identified person who is in charge of the clinical
24 service of the anaesthetic department. It often
25 includes intensive care medicine and the operating
0009
1 theatres, sometimes acute pain services, there is
2 variation from Trust to Trust but there is an identified
3 person.
4 Q. Because of the recommendation of the RCA that there
5 should be an identifiable division of anaesthesia,
6 despite the fact that anaesthetists are involved in
7 providing services right across the range of hospital
8 specialities?
9 A. That is absolutely right. We have done that because we
10 believe you have to have a corporate structure for
11 a variety of reasons, and that if you fragment the
12 services then you do not get the best out of the people
13 that you have there. It is also very difficult for them
14 to deliver a proper training programme if they are
15 spread out over various other divisions.
16 Q. So that Clinical Director of Anaesthesia has
17 responsibility for the quality of anaesthetic services
18 delivered?
19 A. Absolutely. That has been tested by the GMC. There was
20 a case in anaesthesia where there was a locum
21 consultant, not a Fellow of the College, who was not
22 doing good things. This was reported to the Clinical
23 Director. Unfortunately, the patient came to harm. The
24 doctor, who was the local consultant, was struck off the
25 register by the GMC, but the Clinical Director was
0010
1 severely criticised for not taking note of complaints
2 about this doctor and doing something about it.
3 We have reinforced that to every Clinical Director
4 since then, that they have an absolute responsibility
5 for the activities of all the doctors within their
6 department, and that includes trainees as well as
7 non-consultant career grade doctors and the consultants.
8 Q. When you say "all the doctors within the department",
9 those are anaesthetists?
10 A. Those are anaesthetists, correct. I would assume that
11 the same responsibility applies to any specialty. The
12 GMC's ruling was a generic one, and I think it would
13 apply across the board.
14 Q. So how would you expect such a person, then, to follow
15 that up, the Clinical Director of Anaesthesia, that is,
16 to go about reconciling differences of opinion that
17 might arise when the service of anaesthesia was running
18 into difficulties partly because of factors which were
19 outside the control of the anaesthetists and involved
20 other specialties, whether nursing or surgical, to take
21 two broad examples?
22 A. That is part of the structure of how Trusts function and
23 the Clinical Director has a place on the management
24 structure, which varies slightly from Trust to Trust,
25 and one would say that one of the roles of that director
0011
1 is to make certain that, if there are deficiencies in
2 their part of the service, it is drawn to the attention
3 of the Trust and it is rectified.
4 I think the College has taken the view that the
5 minimum requirement for a department is that they run
6 emergency services because, clearly, if they cannot do
7 that the hospital must close. After that, the number of
8 anaesthetists and their activities and what they do with
9 the resources depend on what the Trust wishes that
10 department to do on an elective basis. We have all
11 said, and there are guidelines which have come from the
12 Association which the College endorses, which relate to
13 the space requirements, staffing requirements,
14 et cetera, to provide elective services.
15 But the baseline requirement for any anaesthetic
16 department in an acute hospital is to cover the
17 emergencies, because clearly if that cannot be done the
18 hospital cannot function.
19 Q. But if there are problems in the management of
20 anaesthetic services, the answer is that the Clinical
21 Director would be expected to take that up, higher up
22 the echelons, as it were, of Trust management?
23 A. Absolutely. If they came to the College for help we
24 would try and help them. Our role would be advisory but
25 we would be very willing to help, and on occasion we
0012
1 have done if there has been a problem. If the Trust
2 invites us, because we cannot arrive uninvited, we have
3 sent senior members from the College and from the
4 Association to try and help resolve matters, and that
5 has been quite successful.
6 Q. The question I was asking was the balance of
7 responsibility or involvement between, firstly, the
8 General Medical Council; secondly, the Hospital Trust
9 and, thirdly, the Royal College of Anaesthetists or
10 other Colleges in, as it were, regulating, to use that
11 word in its loosest sense, the competence and
12 performance of individual practitioners?
13 A. I understand the question. The reality is this. If you
14 take the General Medical Council first, they have the
15 ultimate sanction in that they control the register, but
16 they have no power to go and visit anywhere, they have
17 to wait for a complaint, and under the law that operates
18 it has to be a serious complaint. Up to 1st July 1997
19 they could only look at specific cases. They can now
20 look at patterns of performance, but, nevertheless, they
21 are, I think, at the end of the line, because it would
22 take a while before something comes to them.
23 The College, again, for an individual
24 practitioner, would have to wait for a report, although
25 we could pick up problems in a department when we do
0013
1 a training visit. But, as I indicated, that is for
2 training specifically, it is presumably training, and
3 not to look at the clinical service per se.
4 The Trust is the right place. That is where the
5 work is carried out; that is where it should be done,
6 and they have mechanisms to deal with that. They can
7 prevent a practitioner from practising, they can suspend
8 a practitioner, they can report him to the General
9 Medical Council if they wish, they can go down the
10 procedures laid down by the Department of Health for
11 suspension, and so forth. And I would say, as the prime
12 group who look at quality clinical practice day by day,
13 that has to be locally within the hospital, and as far
14 as an anaesthetic department is concerned, that is
15 a prime responsibility of the Clinical Director.
16 Q. So you are saying that the Trust represents what you
17 might call the "front line" of quality, or scrutiny of
18 the quality, of clinical practice?
19 A. I think they have to, because there is no means of
20 anybody externally knowing about that until there is
21 a serious problem. We are based in London. It is
22 unlikely we will know what is going on anywhere else in
23 the land until somebody tells us about it, whereas that
24 is an absolute responsibility. Now, with the clinical
25 governance, of course, it starts with the Chief
0014
1 Executive, but it has always been, in my view, an
2 absolute responsibility of the Clinical Director of the
3 service to make sure it is properly delivered and, if
4 there are problems, to address them.
5 Q. You describe the GMC as representing what you might call
6 the "end of the line" in terms of acting upon
7 complaints. It is right, I think, that your statutes
8 require you to follow the judgment of the GMC in
9 striking off any practitioner, or removing from
10 membership any practitioner, who has failed to meet
11 proper professional standards.
12 If we look at page 7 of your statement where, at
13 paragraph 5.1 you summarise the position, it follows
14 that you do not have power, as I understand it, under
15 your ordnances, to discipline for clinical incompetence
16 without the prior decision of the GMC; is that right?
17 A. That is correct.
18 Q. The corollary of that seems to be that in fact you have
19 never actually had to exert that power; is that right?
20 A. That is also correct. I should say, we cannot, in law,
21 prevent a practitioner writing "FRCA", to have our
22 Fellowship after their name, even if they refuse to pay
23 us any money. We can write to them and say, "We would
24 rather you did not", but in practice we cannot prevent
25 them. It is a qualification, and that has already been
0015
1 tested. People have charged it, not against our College
2 but I think against some other Colleges.
3 We have, I guess, a sanction to write to the Trust
4 where they are employed and indicate that they are not
5 in good standing, and so forth, but it would be up to
6 the Trust to decide whether they wished to continue to
7 employ the doctor.
8 Q. I think that follows from a point you were making at
9 another point in your statement, which is that there is
10 no requirement for anyone, once he has passed the
11 Fellowship examination, to keep themselves in what might
12 be called "good professional standing" by way of
13 continuing medical education?
14 A. Well, again, it is a voluntary system. We, like every
15 other College, operate a points system, which we started
16 in 1995. It says in there, in the rules, that if
17 a practitioner does not have the requisite number of
18 points at the end of five years, we will look to see
19 whether there should be a trainer and if 20 per cent of
20 the Department does not have the points, we would need
21 to see whether that department could act as a training
22 department.
23 We actually have started earlier than that,
24 because when we do a visit to a hospital now, they fill
25 in a computer form as to what is going on in the
0016
1 department, page 1 of which indicates the names of all
2 the consultants and what their activities are with
3 regard to training and there is a column there which
4 says, "Have you got your CME points?" The visitors
5 check that to make sure the details are correct for the
6 other issues, but we make a specific point of asking
7 about those doctors who say they do not have their
8 points, why that is, if it is a mistake, and if not, is
9 something going to be done to rectify it. So we do put
10 pressure on the system. I should say that the take-up
11 on the points system in anaesthesia is very high.
12 Q. That is the existing situation of continuing medical
13 education?
14 A. Yes.
15 Q. In your statement you deal with the further proposals on
16 that?
17 A. Yes. We do wish to change that. Like everybody else,
18 we think the points system has limitations. It is easy
19 to do in the sense that you can count it. The
20 relationship between having points and competence is not
21 proven, and we are, like everybody else, looking at
22 a system of continuing professional development, which
23 obviously would include the points but will have other
24 things in there which we believe are a better measure of
25 the competence of the practitioner, and that is to get
0017
1 ready for the revalidation, which we support, which the
2 GMC is proposing. We think it is a proper way to
3 proceed. What we are concerned with now is how it is to
4 be done in a practical fashion.
5 Q. To return to the point that if the GMC represents the
6 end of the line, as it were, of the monitoring and
7 scrutiny of proper professional practice, is there any
8 case for the College getting more directly involved or
9 involved at an earlier stage in the scrutiny of its
10 members or fellows?
11 A. You are asking now the question about what is the
12 difference between being a friend and being the police.
13 That is always a problem for colleges. I think the view
14 of the College at the moment would be that we wish to be
15 the body that sets the standards for revalidation, so
16 there is a national standard which, wherever you
17 encounter anaesthetists, it would be the same. We would
18 wish to have control over that. If somebody did not
19 meet the standard, initially we would think they would
20 be identified locally and every effort should be made to
21 make the practitioner comply with the standards. If for
22 various reasons they cannot do that, then the Trust
23 could take action immediately or report them to the
24 General Medical Council. Again, we would support that
25 if every effort has been made to make sure the
0018
1 practitioner cannot keep up to date, or keep up to
2 whatever the standards are going to be for revalidation.
3 Q. So ultimately you see the structure as running from
4 Trust to General Medical Council and from thenceforth to
5 the Royal College of Anaesthetists?
6 A. No, we would like to see the standard the same
7 throughout the United Kingdom and that standard is set
8 by the Royal College, which each Trust would use, so
9 wherever the doctor is it is the same, but the sanctions
10 clearly have to come first of all locally, because that
11 is the only way of determining whether the doctor is
12 keeping up to date, and if that cannot be resolved
13 locally then, at the end of the day, that is what the
14 General Medical Council is there for.
15 Q. Those were questions arising really out of the formal
16 position of the College in terms of regulating its
17 fellows or members.
18 If we could turn, perhaps, to the role of the
19 fellowship examination in a little more detail, it is
20 addressed initially at paragraph 6.1 of your statement,
21 or 6.2, which is at page 9.
22 There you set out the history of the fellowship
23 examination and the role of the College in scrutinising
24 the standards of training, which is obviously an
25 inter-related issue, although a separate one.
0019
1 If I could perhaps just take you back first to
2 page 4, and paragraph 2.4, you say there that it is
3 important for the Inquiry to appreciate that the nature
4 of membership of the RCA, as of other colleges, is and
5 always has been voluntary, although it is now in
6 practice necessary to take and pass the fellowship
7 examination to gain admission to the specialist
8 register. You then talk about the fact that such
9 continuing medical education is not a compulsory
10 activity.
11 Can I just explore with you the meaning of the
12 word "now" in that sentence? How does that contrast the
13 existing position with the position at an earlier period
14 during our period of Inquiry?
15 A. As you know, the specialist register was established on
16 1st January 1997, and before that there was not
17 a specialist register. I think the College then, and
18 the Faculty before it, was very keen, I think we were
19 probably among the keenest of the colleges, to ensure
20 that people had completed a proper training programme
21 before they took up a consultant position, but there was
22 a wide variation. There was no absolute requirement to
23 have a certificate of accreditation as it used to be in
24 those days, or necessarily to have finished all of
25 Senior Registrar training and so forth. We were one of
0020
1 the few groups, and we were fairly heavily criticised on
2 occasion, for absolutely insisting people had finished
3 their training programme. On occasion there were some
4 heated debates in the Appointments Committee over that
5 very issue. So we were very pleased when the specialist
6 register was established because it confirmed the view
7 we had always had, that people should not be appointed
8 to a consultant position unless they had completed
9 a recognised training programme and were on the
10 register, so in a sense the value of the fellowship exam
11 went down a little bit. It is a requirement in the
12 training programme, but what you now need to be
13 a consultant of course is a certificate of completion of
14 specialist training or an equivalent and we have
15 supported that absolutely, because it is very important.
16 The reason that we have been keen on it, of
17 course, is that over the years there have been times
18 when there has been a shortage of anaesthetists in
19 training and some hospitals wished to appoint people who
20 were not fully trained as an expediency measure, which
21 we have always opposed, not always with 100 per cent
22 success. Now we feel things are a lot better. There
23 are no consultant appointments to my knowledge of
24 individuals who have not completed a training programme
25 and are on the specialist register.
0021
1 Q. There are a number of threads in that. Perhaps the
2 first is the recognition by the College that the
3 specialty of anaesthesia has been a shortage one and
4 that there has been a shortage of suitably qualified
5 candidates for consultant posts.
6 Is that something that has been true across our
7 period from 1984 to 1995?
8 A. It has gone in cycles, I think. It is not true at the
9 moment. There is no shortage at the moment. I think
10 the difficulties in the past were that the range of
11 activities that anaesthetists engaged in accelerated
12 dramatically. That is borne out by the Audit Commission
13 report. There was rapid expansion and we did not have
14 the people in the system.
15 The other difficulty, before the current
16 structured training programmes, was that the method of
17 determining how many trainees there should be in
18 specialties was confused, to say the least. It was not
19 done by specialty, it was done across the board. We
20 have made numerous representations to that group
21 pointing out there was a shortage of trainees in
22 anaesthesia and therefore realistically we could not
23 provide trained anaesthetists to fill the expansion that
24 was obviously coming.
25 That has changed with the way trainee numbers are
0022
1 established, it is now done by specialties: not perfect,
2 but it is better. At the moment, if we knew what the
3 decision of the government of the day was to be on the
4 number of consultants -- and they will not actually make
5 a statement on that, but that would help all of us,
6 I guess. Within reason, at the moment, the models are
7 based on a 5 per cent expansion in consultants and we
8 believe there are enough doctors in training in
9 anaesthesia to fill that expansion. Last year the
10 expansion was 8 per cent. Clearly, if it goes on at
11 8 per cent, we do not have enough, so we could forecast
12 another shortage.
13 Q. If shortages have gone in cycles across the years, are
14 you able to help us at all on the pattern of those
15 cycles across 1984 to 1995?
16 A. That would require a little more work than you have
17 now. We need to understand (a) it is a function of how
18 many people come out of the training programme, but
19 (b) there was wide variation up and down the United
20 Kingdom as to where there are shortages. Some places
21 are for various reasons more attractive than others. If
22 you went to a part of the land where people want to work
23 and practice, or a hospital where people believe it is
24 a good place to work they will say they have never had
25 a problem. There are others where they will say they
0023
1 have always had a problem. How you fill the other ones
2 is, if you have enough people, you put pressure on
3 people to go to places which are less attractive.
4 Q. If you are going to describe the attractive post and the
5 unattractive post, what is, as it were, the type of the
6 unattractive post as opposed to the attractive?
7 A. I think obviously teaching hospitals on the whole have
8 always been reasonably attractive, not in London, but
9 outside London. There are obvious parts of the UK which
10 are nice places to live, it would be invidious to
11 mention anywhere in particular, but that is obvious.
12 The places where I have had real problems are those on
13 the edge of the large cities, where you are not quite in
14 the attractive part of the land and you are not quite in
15 the city, and they have always had problems attracting
16 staff.
17 Q. Teaching hospitals would not be those that would be most
18 likely to suffer?
19 A. Some have come and gone. There have been variations
20 there. One would need to look at the particular
21 teaching hospital. In London, it is getting better, but
22 we had a period four or five years ago where it was very
23 difficult to recruit. That was related partly to the
24 mergers going on in London; there was great uncertainty
25 as to where the hospitals were to survive and what the
0024
1 final configuration was going to be. People said "I do
2 not want to be somewhere I am not sure is going to be
3 open in two or three years time". In many large cities
4 that has been a similar problem which is still not
5 finished yet, there has been a major rationalisation of
6 hospitals and that has led to a lot of uncertainty
7 amongst medical staff.
8 Q. If I can take you back to the second strand of your
9 original answer, that was that shortages in the number
10 of people holding anaesthetic training posts did lead to
11 problems on the competence of those applying for and
12 being granted consultant posts on occasions. Can you
13 tell us a little about the scale of that problem?
14 A. I would like to think nobody was appointed a consultant
15 who was not up to competence. The difficulties arose
16 before 1997 when there was no specialist register.
17 There were certainly hospitals who tried to short-list
18 candidates who were not fully trained. That was one of
19 the roles and still is the role of the College assessor
20 who goes to the Appointments Committee. We made a very
21 strong point of saying to assessors, "You are absolutely
22 responsible for making certain that someone is not
23 appointed who has not finished the training programme
24 and is not suitable for the job as advertised".
25 I think that is Trusts -- not so much Trusts, certainly
0025
1 hospitals before the Trust system. Some, I am afraid,
2 behaved better than others.
3 Q. Your answer a little earlier was ambiguous, because you
4 said you would like to think nobody was appointed who
5 did not have proper competence. Is that wishful
6 thinking?
7 A. I would like to think that. I have no means of proving
8 it, obviously. I think it would be fair to say, our
9 assessors have always taken a very strong line and tried
10 to prevent the hospital or Trust appointing somebody who
11 in their belief is not fully trained for the job they
12 have applied for.
13 Q. Picking up the matter we were originally discussing, it
14 is right that the College now has attained a statutory
15 function in its role in granting or assisting in the
16 award of the Certificate of Completion of Specialist
17 Training?
18 A. Well, yes. Our training programme is like all the
19 others. It is recognised by the Specialist Training
20 Authority. We keep track of all the trainees. We keep
21 records of where they have trained; that they have
22 proper assessments done for their training. Obviously,
23 if they have taken our examination or the equivalent
24 examination, we will have records of that, and at the
25 end of the period, we make a recommendation to the
0026
1 Specialist Training Authority that "this particular
2 doctor has finished the training and is suitable to be
3 awarded a CCST". The Specialist Training Authority does
4 a 10 per cent audit on what we have sent them. If they
5 are satisfied, they will recommend that doctor's name to
6 the GMC.
7 Q. If I could ask you to look at page 13 of the statement,
8 and in particular at paragraph 6.23, you make the point
9 there that the establishment of the STA marked the first
10 time in the history of the Royal Colleges when they were
11 given statutory powers, namely, the duty to recommend
12 the award of the Certificate of Completion in Specialist
13 Training and that up to that point, you had been acting
14 by influence and persuasion rather than statute.
15 Why in that context do you welcome, as you clearly
16 do, the statutory underpinning of the role of the
17 College?
18 A. I think there are always individuals who like to
19 challenge established practice, and this prevents them
20 from doing that. It makes it clear that the Royal
21 College is straightforward.
22 I have to say, most people believed that we had
23 statutory powers under the Royal Charter. I am not
24 legally qualified, so I am not quite sure what the
25 actual power of Royal Charters are, but I think everyone
0027
1 in the College, I imagine most anaesthetists believed
2 that the charter did give us that power, but I am not
3 sure that is true. This is clearly a legal power, and
4 therefore it was confirming what we all believed and we
5 therefore welcomed it. I do not think it is anything
6 more complicated than that.
7 Q. Was it something that ended a practical limitation on
8 the role of the College, or was it a symbolic matter?
9 A. I think it is more symbolic, and also it set a date --
10 I think the change of course in the training programme
11 was a dramatic event, because prior to the institution
12 of these training programmes, although we ran a training
13 programme, nobody never ever questioned what we were
14 doing, and people would be trainees for a very long
15 period of time in all specialties. Although there were
16 published standards for it and it had limitations and so
17 forth, it was not approved by anybody; nobody ever
18 looked at it and I think now we have a much better
19 system where we have to convince the competent
20 authority, the Specialist Training Authority, we have to
21 comply with the European directives and the European
22 orders which basically say now the programme has to have
23 a start and a finish, it has to have proper assessment,
24 it has to have a properly defined content; it is not
25 actually a requirement to hold examinations, one can if
0028
1 one wishes, and I think it is a much better way of doing
2 things and it makes it much easier for us to run proper
3 training programmes.
4 In fact, anaesthesia was one of the first ones to
5 switch over and we did not have immense difficulties
6 because many of the bits were already in place. Other
7 specialties have more difficulties because they have not
8 quite done it that way. But we think it is good. The
9 only thing we found a problem is that because we were
10 one of first ones to get going, it is obvious now that
11 with the new things that have come along to go into the
12 programme and the proposed shortage in doctor's hours
13 going down, although the latest government's edict seems
14 to think they are going to increase it, but if that goes
15 ahead, we do need more time. That is why we have asked
16 for our specialist training part of it, our SpR time, to
17 be increased to 5 years from 4. But other than that, we
18 think it is very good.
19 Q. May I ask you, the system that has now emerged with the
20 Royal Colleges having a statutory function in
21 recommending the award of a CCST, is that something that
22 emerged out of a proposal put forward by the Colleges,
23 all of them? How did this change emerge?
24 A. It emerged because a doctor challenged the -- I will get
25 it right: I think he had a certificate of training from
0029
1 Germany -- I believe, I stand to be corrected on that --
2 and the original European directives on professional
3 people have one function only, still have one function
4 only, and that is free movement of doctors and other
5 professionals between the various European countries.
6 They are not remotely interested in quality or standards
7 of training, or anything else, they just wanted free
8 movement -- still do. Therefore, they set some pretty
9 low standards in terms of time, which would not be
10 acceptable in this country, and I suspect not in other
11 European countries either. But that was the purpose.
12 This doctor challenged the system because he
13 applied for a consultant post, not in anaesthesia, in
14 this country, putting down his training elsewhere and
15 was not short-listed on the grounds that he was not
16 properly trained. So he challenged Mrs Bottomley, who
17 was then the Secretary of State for Health, and said
18 that this was in contradiction of European law, and
19 I think he was right, in that sense.
20 So therefore, Sir Kenneth Calman, who was then
21 the Chief Medical Officer, was asked to hold an Inquiry
22 and to set up what people called 'Calman training', but
23 it was really to bring the training programmes in line
24 with European law. To do that, the directive was
25 translated into the European specialist medical
0030
1 qualifications order which was passed in 1995. That is
2 the legislation, as I understand it, which sets up the
3 STA and all the rest of the things you are talking
4 about.
5 Q. I am asking whether this was a role that was emerging,
6 and I am looking there at the statutory underpinning of
7 the role; was this something emerging out of demands
8 from the Royal Colleges, or advocacy for this role on
9 the part of the Royal Colleges?
10 A. I cannot answer that question specifically. I can only
11 speak for the Royal College of Anaesthetists, and we
12 were always very keen to have a properly defined
13 training programme with a start and a finish and all the
14 things that are in there now, which is why, when this
15 new scheme came along, we did not have any great
16 difficulty adapting to it. So I think we had most of
17 those pieces in place, and we have always wanted to make
18 sure that people had a proper training programme so that
19 when they applied for a consultant's post they were
20 properly trained for it.
21 Q. If we look at the past situation with the pre-existing
22 course, and I am looking at page 11 of the statement,
23 paragraph 16.14, there is a summary of the method of
24 obtaining the certificate of accreditation for
25 completion of the approved training programme.
0031
1 The question that would arise out of that is that
2 under a system, as it then existed, was there a danger
3 that issuing such a certificate might mark attendance at
4 the course, or passing through it, rather than being
5 a measure of competencies or skills gained?
6 A. I think that is correct. We still do not have an
7 absolutely competency-based training course. We are
8 working towards that. I might say that it is not
9 a requirement under the European legislation. All that
10 indicates is that there has to be a time element, and an
11 assessment and a content element; it does not mention
12 competency at all. Nevertheless, one would wish to have
13 that.
14 But there is no question that in the past time was
15 the factor that mattered and people cycled through.
16 The only thing to bear in mind is that over that
17 period of time trainees often spent a long time in the
18 various grades and would have much more time in the
19 minimum.
20 Q. Whereas now the time for training is limited and you
21 must pass through the system within a period--
22 A. No, people get confused. It is the minimum requirement,
23 there is nothing about one taking further time and many
24 trainees do.
25 What happens at the moment is that, if we leave
0032
1 this SHO training to one side because that is not what
2 actually counts as far as the European legislation is
3 concerned, if you look at the SpR time, when a trainee
4 gets an SpR appointment that is by competitive interview
5 and they are given a number. That number is actually
6 valid for seven years, although the payment issues as
7 far as the National Health Service and the post-graduate
8 Dean is concerned is four years. But many trainees take
9 time out of the programme and they go and do research,
10 further clinical training, go oversees, et cetera, and
11 keep their number and come back.
12 So the number who finished the training in the
13 four years, do the CCST, that is a small number. Many
14 take more. But that is the minimum requirement.
15 Q. You have been talking about the development of
16 a competency based curriculum, and perhaps we might look
17 at page 365 of your statement. We have there 1998
18 proposals to change the SpR training in anaesthesia.
19 That is the beginning of a document which obviously
20 continues at page 369. If we could take it to that
21 where, if we look at the background, I perhaps might
22 invite you to have a look through the three paragraphs
23 there. In particular, in the second paragraph.
24 The policy of the RCA as set out there is:
25 "To base their assessment tools on the triad of
0033
1 knowledge, skills and attitudes as set out in tomorrow's
2 doctors" and that the RCA has been "... encouraging
3 debate and setting up a pilot project to develop robust
4 methodologies and that in particular notable
5 contributions have been made in the production of
6 a competency based curriculum for SHOs and SpRs, in
7 assessment of clinical performance and also an on going
8 evaluation of simulators".
9 If we go down to the next paragraph, there is
10 a comment there on:
11 "... the nature of the skills that are needed and
12 the variety of skills that are needed by trainees,
13 including the need for reflective behaviour which
14 maintains self-criticism and development, although there
15 is evidence that that cannot be assumed to be present in
16 all consultants".
17 Then carrying on to page 371, if we may, under the
18 heading "Assessment of Clinical Skills" halfway down the
19 page, the paragraph there:
20 "Before skills can be assessed those necessary at
21 a given stage of training need clear definition. This
22 was first done in detail for SHOs in 1994 with the
23 publication of the RCA's document, specialist training
24 in anaesthesia, supervision and assessment, and then
25 followed the following year by an updated implementation
0034
1 guide".
2 That is saying, as I read it, that the first time
3 that clear clarification of the skills to be attained
4 during training were set down, at least in black and
5 white, was in 1994. Is that a fair reading?
6 A. I cannot speak of what took place before. There have
7 been numerous documents, some of which will have come
8 through the Association on what skills and attitudes --
9 but I think that was the first time we sat down to do
10 it, because the specialist training in anaesthesia,
11 supervision and assessment document, that was our first
12 go at getting ready for Calman training, because we had
13 now to define things we had never had to do before in
14 the sense that before that there was no time limit on
15 how long people could train for. It was assumed that if
16 you trained long enough, you would do everything and you
17 would go round. Indeed, that was probably correct.
18 Now we were faced with putting forward a programme
19 where in six years, because we had two years of SHO and
20 four of SpR, every trainee had to do all the things
21 which in the past may have taken much longer than that.
22 So that was the attempt to do that in blocks, to
23 put it together, to say, 'You will only have a trainee
24 for a period of time in this particular area of
25 practice, these are the things we think that trainee
0035
1 should be able to do in that time'.
2 Q. How well defined were the competencies or skills that
3 a trainee was meant to obtain before that
4 crystallisation process took place?
5 A. In that particular document they were quite well defined
6 and that is why we had some forthright discussion about
7 it.
8 Q. And prior to that?
9 A. I do not think it was well-defined prior to that;
10 I doubt it. That document, of course, contains
11 information from previous ones, it is always the way,
12 but I do not think it had been laid down too carefully
13 before then. Nobody did. It was not a requirement to
14 do that.
15 Q. You have talked about the anaesthetists being forward,
16 really, in the development of competency based curricula
17 in defining the skills needed for anaesthetic practice.
18 So how does the general picture on training you have
19 just been describing compare with those in other
20 disciplines, for example, surgery?
21 A. I cannot answer that question. I do not think I am
22 competent to answer that. The reason anaesthesia does
23 this, of course, is quite straight forward. It is that
24 much of our clinical activity revolves around making
25 decisions when all the information may not be available;
0036
1 you are dealing with sometimes very ill patients and if
2 you get it wrong it will be a bad outcome; and also we
3 have a number of technical skills which you need to be
4 able to do and often have to be able to do them now,
5 there is not time to think and sometimes not even time
6 to send for help.
7 So it is very important that those things are
8 defined and that people are well trained to do those at
9 the time. That makes us a bit different from some other
10 specialties where there is often a little more time, one
11 can send for help and there may not be the immediacy for
12 manual skills, and so forth.
13 Q. If I can take you forward to page 372. At the top of
14 the page the discussion starts:
15 "Results from the appraisal and assessment of
16 trainees on the present 4-year SpR training programme
17 have been a major influence in wanting to extend the SpR
18 programme by another year".
19 That is, of course, the thrust of the document we
20 are looking at. Then, they set out two difficulties
21 with the present programme. Firstly, insufficient time
22 for a trainee to become both competent and competent in
23 subspecialty work by the time of appointment to
24 a "specialist" consultant anaesthetist post. Secondly,
25 the difficulty in attaining the standards as
0037
1 a generalist consultant anaesthetist.
2 May I ask you: is that a statement of a general
3 problem or is that descriptive in particular of the
4 post-Calman training scheme that had been devised?
5 A. It partly relates to Calman, because the time went
6 down. The other thing it reflects is a major change in
7 the National Health Service in that over the last five
8 years perhaps the amount of clinical work going through
9 hospitals has gone down, partly because of an
10 unprecedented rise in the number of emergencies so that
11 elective patients cannot get in, and therefore there are
12 waiting lists.
13 Therefore, when you look to see, when you want to
14 train anaesthetists, obviously they need to be able to
15 deal with emergencies, but much of what is described
16 here is elective work and it is not going on. So that
17 is a real problem.
18 When you come to the specialist area, it is really
19 a particular problem in that there may not be enough
20 cases available. That is another reason for wishing to
21 extend it, because if we want to be sure that people
22 have adequate exposure to the specialist areas which are
23 listed here, at the moment the number of cases are just
24 not going through the hospitals in the way they used to.
25 Q. So if we could pin that particular problem, or these
0038
1 problems, down in time-scale, are we talking post-1995,
2 pre-1995, or around that time?
3 A. My feeling would be that that is something which has
4 gradually increased over the last five years. It
5 relates to this unprecedented demand for emergency work,
6 for which there are numerous explanations.
7 I work in a major teaching hospital in the East
8 End of London. Much of my routine anaesthetic work is
9 related to the surgical unit who do major colorectal
10 surgery. The number of cases we have done has gone down
11 and down in the last five years because we cannot get
12 the patients into hospital because the wards of full of
13 emergencies.
14 Q. If I can take you back to page 369, to the last
15 paragraph there which contains a sentence we have
16 already looked at about "... The numerous skills needed
17 to practice as a consultant anaesthetist", and it talks
18 about "factual knowledge, practical skills, behaviour,
19 personal qualities, which are important, but also,
20 reflective behaviour which maintains self criticism and
21 development and there is evidence that that cannot be
22 assumed to be present in all consultants".
23 Can you help us, firstly, on the existence or the
24 extent of the evidence to which that paragraph is
25 referring?
0039
1 A. Not in terms of numbers, but it is an issue now which
2 I think, again, all specialties are trying to address.
3 It was never part of the training programmes. As we
4 know, and I think it is absolutely right, the general
5 public as a whole, and patients in particular, are now
6 asking much more about their treatment and what goes on
7 in the hospital and questioning what the doctors do. In
8 my view, they should have been done long ago. But that
9 is coming about, and we need to have doctors who
10 understand that and accept that that is part of what
11 they do.
12 Q. What it is discussing there is reflective behaviour, or
13 self-reflection, amongst consultants, assessing of their
14 own performance, their own skills. Is that something
15 which, as it stands, is part and parcel of the
16 consultant's 'culture', if I might dub it so?
17 A. You mean at the present time? I am sure it is true of
18 some consultants. I doubt it is true of all. It should
19 be, is the simple answer to that, but that is something
20 where we are dealing with a large number of people with
21 individual behaviour.
22 Q. Of course, and it will no doubt vary from person to
23 person, as you point out. If I push it back to 1984,
24 and let us say the period from 1984 to 1990, would it be
25 something that one would find an even smaller number of
0040
1 consultants at that time?
2 A. I would have thought so. I think there has been
3 a change in culture. It was not part of one's...
4 Certainly, when I went through training this was
5 something... I think it was always true.
6 I went to medical school in the north of England;
7 they all think I went to a medical school in London.
8 I actually have what is called a diminishing degree
9 because when I was a medical student it was the
10 University of Durham, but you cannot get a degree from
11 there any longer. It is now the University of
12 Newcastle.
13 I can remember when I was a medical student,
14 certainly on many of the firms, we were told very, very
15 clearly that relationships with patients and the general
16 public was a very important part of a doctor's
17 behaviour, and many of the firms used to do that as part
18 of the training. Now, I am sure, that is true in most
19 medical schools, but as a culture I do not think it was
20 widespread. I think it is now changing, and not before
21 time.
22 I wonder if I could just go back to one thing
23 I said earlier, where I mentioned the rise in
24 emergencies. That is not the only reason, of course,
25 why we extended our training programme, but it is part
0041
1 of the problem. The other reason we have extended it is
2 that we are keen that everybody, if they wish to
3 specialise in certain areas, can do that. If you have
4 a shortened time, of course it is more difficult to
5 cycle everybody through there.
6 So that is an issue in that, because we are still
7 training people across the generalities and for what are
8 called the core topics, everybody should do that, and
9 then they need to decide what their special interests
10 are going to be. It just is not practical, and it does
11 relate partly to what is available in terms of clinical
12 work, to do that in a reasonable time-frame.
13 The reason we chose originally to do two years and
14 four, in a sense that is what every other specialties
15 were doing and we wanted to do the same, but it is now
16 clear that it cannot be done in that time. So that is
17 a reason. But there is no question that the emergency
18 workload is a factor, and I assume that is a factor with
19 other specialties, too.
20 Q. If I could go back to the question of the culture of
21 self-criticism and also, perhaps, because it is linked
22 to this, working as a team. You were saying that as
23 part and parcel of your medical training that sort of
24 attitude was encouraged. You also said that it was not
25 necessarily the case that that form of training was
0042
1 always contained within medical education, at least at
2 that time.
3 Can you help us as to the time-scale within which
4 this sort of issue has been developing as part and
5 parcel of the training for a doctor, for a consultant?
6 A. I would be hard put to put a time on that. I have to
7 say, I spent ten years working in North America, and it
8 is part of the culture there. England is very
9 different. Canada has essentially a National Health
10 Service as we have here, but the relationship, and it is
11 a key one, is that the doctors are not employees of the
12 hospital, they have privileges to work there which are
13 renewed every year, and, of course, part of that is all
14 the things that we have been talking about so far. The
15 doctor needs to demonstrate that they are doing those
16 things.
17 So it is different there. I think it is changing
18 here. I thought when I came back in 1990 there had been
19 changes, and from then on it has accelerated. I imagine
20 with this Inquiry you are getting the attention of a few
21 more doctors, which is probably good.
22 Q. What you are suggesting by that answer is that, in
23 effect, putting this subject on the curriculum in
24 a medical training establishment may not be as
25 influential as the sorts of incentives or pressures that
0043
1 are exerted upon consultants throughout the course of
2 their continuing practice thereafter?
3 A. I think you need to do both. I like to think the
4 University of Durham was very forward looking; it was
5 a very good medical school. I am not sure every medical
6 school was doing it. I am sure you are right, it has to
7 be both. Medical students are subjected to enormous
8 pressures during their undergraduate training and that
9 has to continue when they qualify, I am sure.
10 Q. Can you help us with one further reference on this
11 document, page 370, the second paragraph there:
12 "Anaesthesia differs from some specialties in that
13 all new recruits are assumed to have little knowledge of
14 anaesthesia per se on appointment."
15 Can you help us with the meaning of "on
16 appointment" in that context?
17 A. It means when they take their first SHO appointment.
18 That will change now. Up to now, not every medical
19 school has a rotation in anaesthesia. Many do. Most
20 have at least the option. What is now changing is they
21 are now pre-registration house appointments in
22 anaesthesia, they have just started, and I think that
23 will help us. Certainly, if you go back one year, most
24 people taking their first SHO appointment will be
25 unlikely to know very much about anaesthesia, although
0044
1 they may well use it as a postgraduate topic.
2 Q. The document continues: "So there is a long established
3 tradition of formal introduction to new skills, the
4 setting of targets ... and in particular, a one-to-one
5 supervision for the protection of patients being the
6 norm in the early stages of training."
7 You are discussing there a very specific set of
8 steps taken, ultimately perhaps for the benefit of the
9 patient, to protect them during the course of the
10 training of a trainee.
11 How does that issue continue, or impact upon, the
12 practice of consultant anaesthetists once appointed to
13 such a post?
14 A. You are quite right, that is done primarily to protect
15 the patients, that is obvious. I think, again, it
16 reflects on what anaesthetists do, in that you could not
17 take someone who had no knowledge of the topic and let
18 them start give anaesthetics unsupervised; the results
19 of that might be very bad. So I think that one-on-one
20 supervision has always been there. I imagine that was
21 there right from the start.
22 I started anaesthesia in 1961 and there were no
23 recognised training programmes in those days, but I went
24 round with a senior anaesthetist one-on-one until he was
25 confident that I could do things when he was not
0045
1 standing next to me. So that has always been the case.
2 Are you asking what happens when somebody becomes
3 a consultant? I think by then they would feel they had
4 undertaken a fair old period of training. They would,
5 in the last year or two, have been working unsupervised
6 in the sense that somebody would not be standing next to
7 them, and we get people ready for independent practice.
8 It is a feature of being a consultant in the National
9 Health Service that you are in independent practice and
10 you are not directly supervised.
11 Q. If one takes the parallel of a surgeon, for instance,
12 there are obviously instances in which that surgeon will
13 have to master a new operative technique. What I am
14 asking is for your opinion on that by way of analogy
15 with anaesthetists, whether they confront such similar
16 situations and, if so, what would be the practice to
17 protect patients in such a situation?
18 A. I think if somebody was starting on something totally
19 new there would be a number of ways of doing it. If
20 there was somebody else in the Department who was doing
21 it you would go and work with them until you are
22 confident you could do it. If there was nobody in the
23 Department, you would arrange to go to wherever it was
24 practised, and, for certain things that have come along
25 new, places have offered training courses; 'Come and
0046
1 work with us', and so on.
2 Many people do that, continuing on through their
3 career. I mean, going to see one of the people up to
4 this very important part. A key part of the continuing
5 professional development that we are looking at is that
6 we are encouraging people. At the moment you can get
7 extra CME points if you go and work with somebody who is
8 doing similar things to you, either in your own hospital
9 or, if it is not present there, go somewhere else. We
10 have offered that for some time now to try and encourage
11 people to keep up to date and learn things as they go
12 along.
13 Q. Does that imply that the process of setting what you
14 might call 'guidelines' for practice in learning new
15 operative or anaesthetic procedures is something that
16 has only been standardised or evolving in the last few
17 years?
18 A. Yes, I think that would be connect.
19 Q. So if one took it again back to 1984 through to the
20 early 1990s, what sort of guidance would be on offer to
21 a consultant anaesthetists who is facing the development
22 of a new form of anaesthesia, perhaps the introduction
23 of a new drug, something like that, and they are having
24 to decide how best to train themselves in that area of
25 the practice?
0047
1 A. Various things. If you take new drugs, it is in the
2 interests of the drug company to make sure the drug is
3 used properly. So they have usually put in pretty major
4 efforts of running course, training opportunities,
5 funding meetings, all those sorts of things. That has
6 been going on for a long time. I think the drug side is
7 reasonably well-developed. One might question sometimes
8 the interests of the drug companies in moving things in
9 a particular direction but, nevertheless, that has
10 always been reasonably well done, I think.
11 But it is an issue in that there is nothing to
12 prevent any medically qualified person using a new drug
13 without any training or information, and the only
14 consequence of that would be if something goes wrong, of
15 course, and then there would be the difficulty of
16 saying, "Well, you have used this drug without any
17 proper information". Then you could say that is not
18 correct, and I would agree with that.
19 When it comes to procedures, it has always been
20 more difficult, because it has been relatively rare for
21 something totally new to start up from scratch. It is
22 usually a development of something else. On occasion,
23 of course, when something new has come along there has
24 been nobody to talk to because it is new and you have
25 had to rely on the skill of the people there. Some of
0048
1 it went back to when transplantation began, for
2 example. Much of that was developed on animal work to
3 begin with, and many of the people involved...
4 I mean, I started doing renal transplants many
5 years ago but I originally used to help the surgeons
6 when we did the animal work to develop how we were going
7 to do the transplantations. So in that sense we learned
8 in that way. And in many new surgical procedures, of
9 course, that is how they have started. They have done
10 animal work first and then transferred it to human
11 beings. Cardiac surgery is a good example. That is
12 another way it started.
13 Q. I think what you are describing is a situation where
14 each consultant would be thrown back on his or her own
15 professional judgment, coupled with collaboration of
16 other colleagues, surgical colleagues in particular, if
17 one was dealing with these surgical procedures for
18 instance?
19 A. Yes, that is true. If you look at laparoscopic surgery,
20 which is probably the last introduction, that was not
21 well introduced and there were some serious problems
22 there in terms of the training of individuals doing
23 laparoscopic surgery. Now, of course, there are
24 training programmes all over, some run by the Royal
25 College of Surgeons, and it would be, I think,
0049
1 inconceivable and unacceptable for any practitioner to
2 start on laparoscopic surgery, from a surgical point of
3 view, without having done that sort of training.
4 The anaesthesia for that though is more
5 interesting, because there are some anaesthetic aspects
6 of laparoscopic surgery which were important, but it was
7 a development in that sense in that laparoscopic type of
8 things were going on for many years and there was not
9 a moment in time, I suspect, when somebody said, 'Right,
10 that is when this is going to start'. So it is more
11 difficult for anaesthetists.
12 Q. There is no particular alarm bell or signal that will
13 ring to say, "This is something that goes beyond the
14 small incremental steps we have been taking to amount to
15 something where my skills are so limited that I have to
16 step outside my own department to ask for further
17 assistance"?
18 A. Again, one would hope. Some of the activities would
19 come from the College, some from the Association. We
20 run regular updates, we run CMA meetings. These things
21 are on the programme all the time. They go around to
22 every anaesthetist, and anything new that is coming
23 along, or where there is an area where there are
24 difficulties, there are regular programmes to attend.
25 We cannot force a practitioner to attend them, but they
0050
1 are there and they are well publicised and they are well
2 attended.
3 Q. If I can take you back very briefly to page 10 of your
4 statement to clarify one small point, because we have
5 been talking about the setting of standards for the
6 duration and content of training. If we look at
7 paragraphs 6.8 and 6.9, in particular you say at 6.9:
8 "Candidates for the final Fellowship examination
9 were required to completed at least 30 months of
10 training in anaesthesia."
11 To clarify that, is that in addition to or
12 including the minimum of 12 months you refer to in
13 paragraph 6.8?
14 A. No, that includes it. If I could just make a comment on
15 the examinations. I think before the advent of the
16 CCST, I think certainly in this country and around the
17 world, the Fellowship was recognised as a standard and
18 people thought somebody who had both parts of the
19 Fellowship, or when it was a three part examine had all
20 three parts, was a fully trained anaesthetist. I do not
21 think the Colleges ever recognised that, because these
22 are tests of knowledge, they are not tests of competence
23 per se, and, of course, they are not at the end of the
24 training. We view them as a national standard of test
25 of knowledge which the College feels should be there to
0051
1 demonstrate that wherever somebody trains in the United
2 Kingdom there is a level and standard of knowledge, but
3 that is all.
4 The primary examine we run now has an OSCI
5 component to it, an objectively structured clinical
6 examination, which some people believe is a test of
7 certain competencies. But the rest of the examinations
8 we run are knowledge tests, they are not competence
9 tests; and they are part of the training programme, they
10 are not the only part.
11 Q. I think, if it is convenient to you, we will break now
12 for a quarter of an hour, and then resume for another
13 hour or so with the intention of aiming to complete your
14 evidence in a long morning rather than to take
15 protracted breaks in the middle, if that is acceptable.
16 I think, Chairman, that probably means resuming at
17 25 to 1, or 12.30, depending on your watch.
18 THE CHAIRMAN: Let us say 12.30 on my clock, because my
19 clock says 12.16, and then we will take a late lunch and
20 see if we can complete this evidence before lunch. So
21 we will reconvene in 15 minutes.
22 (12.20 pm)
23 (A short break)
24 (12.35 pm)
25 MISS GREY: If I could turn, perhaps, Professor Strunin, to
0052
1 the question of the scrutiny of the teaching hospitals
2 by the Royal College of Anaesthetists by its programme
3 of accreditation of these, you refer to this matter
4 briefly at paragraph 5.4 of your statement, which is
5 page 7.
6 You talk there about this programme of inspections
7 of hospital posts being a powerful tool in regulating
8 the performance of consultants and teams.
9 Can you just tell us why you would consider it to
10 be a powerful tool?
11 A. There is no hospital as far as I know which could
12 maintain its clinical services if the trainees were
13 removed. I think that usually gets the attention
14 straight away.
15 Q. If we can turn on, then, to the point where you address
16 this in more detail in your statement, to paragraph 6.27
17 at page 14, you have said already, in the earlier
18 passage, that the visits are at least every five years,
19 and you say at paragraph 6.27 that visits to the Bristol
20 Royal Infirmary were undertaken during this period, and
21 that the reports of the visits have been carefully
22 scrutinised but contain no information on paediatric
23 cardiac anaesthesia; and that there is no data from the
24 reports of the visitors which would throw any light on
25 the matters which led to the current Inquiry.
0053
1 Can I just ask you to give some background to that
2 paragraph. Have you been able to look at all the
3 reports of visitors yet?
4 A. Not quite. When we wrote what we have here, we were
5 still having some difficulties going back to 1985. As
6 I indicated to you in the statement earlier, the College
7 was formed in 1992 and before that we were a faculty of
8 the Royal College of Surgeons.
9 In the move from the Royal College of Surgeons in
10 Lincoln's Inn Fields to our premises in Russell Square,
11 I am afraid the archiving was not quite as desirable as
12 it might have been. I think the documents are
13 available, but they are not to hand at the moment.
14 I got the last set together just before the weekend.
15 I was proposing to go through them again and make sure
16 there was nothing in the previous ones and obviously let
17 you have copies of them all.
18 I think it is worth pointing out that visits to
19 hospitals look at training, not specifically at the
20 level of clinical services. The only time that would be
21 brought to the attention of visitors is if there was
22 some major problem; there clearly may have been
23 a problem here in Bristol, but at the time of the visits
24 that was not something which was public knowledge and
25 would not therefore have been discussed.
0054
1 Q. Firstly, it would be very helpful to the Inquiry if you
2 could deliver the actual reports of those visitors.
3 Secondly, if it is the case that the College, as we
4 know, was created in 1992, were you able to look at
5 reports of visits prior to that date?
6 A. Yes.
7 Q. You were?
8 A. Yes. We have tried to find all the visits back to
9 1985. As I say, the reason they are not to hand, and
10 I apologise for not bringing them today, is that finding
11 them in the archiving system is not straightforward.
12 The last lot were delivered to me on Friday. As soon as
13 I have had a chance to look through them all, I will
14 send them to you.
15 Q. It may be that the question is premature and it may be
16 something you need to come back to when you have had
17 an opportunity of looking at all of them.
18 Nevertheless, looking at that paragraph in your
19 statement, against the background of events in Bristol,
20 where we now know that the standard of paediatric
21 cardiac surgery was at least a matter of concern to at
22 least one of the consultant anaesthetists during broadly
23 the period 1990 to 1994, to put it very broadly and
24 possibly inaccurately, and secondly that led to
25 a breakdown in confidence or communications possibly
0055
1 between the members of that team, the question that
2 would be raised by that statement is, why was that not
3 something that was picked up as part of an accreditation
4 visit?
5 A. I think I need to look at the time of the visit in
6 relation to the events -- they may not have coincided --
7 obviously, to answer that for you. If I briefly outline
8 what happens when a visit takes place, that may help
9 you.
10 The College has in every hospital where there are
11 trainees one consultant identified as the college
12 tutor. That is our reference person. Each region has
13 a regional advisor who looks after a group of
14 hospitals. When a visit is planned to the hospital it
15 goes through the college tutor. The visitors -- two
16 members of Council or sometimes one member of Council
17 and one from our training committee -- would meet with
18 the college tutor, the Clinical Director of the
19 Department and the regional adviser and look at training
20 issues in that particular hospital.
21 The only time that it would be drawn to the
22 visitors' attention on a major clinical matter is if
23 that was interfering with training in some way.
24 The second part of the visit is where this might
25 come up. The second part of the visit, apart from
0056
1 looking at facilities, meeting other consultants and so
2 forth, a key part of the visit which the College puts
3 a lot of emphasis on is one-on-one confidential
4 interviews with trainees. They sometimes raise all
5 sorts of issues. Obviously one has to put those in
6 perspective. If a particular trainee picks on something
7 one might not take that too seriously. If a group of
8 trainees says "Here is an issue", one would. One would
9 raise that with consultants. But again, the emphasis
10 would be on training. If there was a major clinical
11 problem, one would expect to hear about it, but one
12 might not. I think that is the background to it.
13 Q. The way in which I phrased the question, I may not have
14 succeeded in my intention, was to suggest that if, in
15 a department, the confidence between members of
16 a clinical team was either frayed or under severe
17 stress, would that not be something that was relevant to
18 the training of anaesthetists?
19 A. Undoubtedly, but again, that would have to be brought to
20 the attention of the visitors by the College tutor, the
21 Director of the department and it would be picked up
22 from the trainee interviews. If it is not picked up
23 there, clearly one would not have identified it. If it
24 was identified, then it might well be an issue.
25 Q. But it would be something that would have been certainly
0057
1 of concern to the Royal College of Anaesthetists if it
2 fed through the system?
3 A. Absolutely. I think what I said in my report in 6.27,
4 that is based on I think the last two visits. We did
5 have the paperwork and I could find no reference in
6 there, other than, as I indicate here, there was
7 a reference that the paediatric cardiac anaesthesia was
8 a good rotation, and that would be the view of the
9 trainees at that time. I will get you the date so you
10 can look at it in time course.
11 Q. If you would, we would be grateful. If in particular
12 you have any further comments on the issue of what, if
13 anything, is said about the system of accreditation by
14 events so far as one knows them at this stage, of
15 course, that of course would also be of assistance to
16 the Inquiry.
17 A. We are very anxious to help this Inquiry. As I have
18 said, I think our archiving system leaves a bit to be
19 desired, not our fault in this instance, but we
20 certainly will provide you with that. But I would
21 emphasize that these visits may well have been at five
22 year intervals if things are going well there, and they
23 may not be contemporaneous with events you are looking
24 at in the Inquiry.
25 Q. You mentioned at an earlier stage that you visit at
0058
1 least every five years. Would there be a particular
2 trigger for visiting more frequently than that?
3 A. Yes. When a visit takes place, if there are problems,
4 these are identified. The mechanism is that the
5 visitors try and make sure, before they leave the
6 hospital, that the consultants, preferably the Chief
7 Executive if it is a management issue, agree there are
8 problems. They then write a report. This goes to the
9 Council of the College, and the Council issues the
10 letter which may say, "The hospital has been approved
11 for a further five years", or it may it indicate that
12 "The following issues need to be resolved", and will
13 put some time-scale on that. This may vary from
14 a further visit any time during the next five years to,
15 if there are serious problems, a clear deadline saying
16 there is now six months or a year, whatever it may be,
17 to rectify the problems, and if they are not rectified
18 then a decision about continuing training would need to
19 be taken. We might on occasion, if it was something
20 simple, rely on the College tutor to notify the College
21 that it had been rectified. If it was more complex,
22 that would be a role for the regional adviser, and if
23 there was a serious issue, a further visit would take
24 place.
25 Q. If I could just ask you to look back towards page 8 of
0059
1 the statement, and paragraph 5.6 in particular, you
2 speak there about the fact that "In two recent visits
3 the visitors recommended that one anaesthetist's
4 performance was seriously deficient."
5 Is that a sanction or a step that you are aware of
6 as being taken on other occasions?
7 A. I think this is a fairly new initiative which came out
8 of our Good Practice Guide. I think the point to make
9 here is that this is not a sanction that the College
10 has; this is advice to the Trust. The way we have done
11 this is, if an anaesthetist calls to the College, or
12 a Trust does occasionally, or sometimes a Medical
13 Director may phone for advice, we say if they have
14 exhausted all the local remedial action, that is the
15 first point, and they are seriously concerned about
16 a doctor's actions or performance, then with the
17 agreement of the Trust and the doctor the College will
18 send a senior college person and a certain member from
19 the Association of Anaesthetists to advise the Trust,
20 and they meet with the doctor and anybody else relevant
21 to the thing and give their advice.
22 Up until now, the advice has been taken and we
23 indicate what has happened in two cases here. The
24 numbers are small. I think most colleges are doing
25 similar things. It has always been done on an informal
0060
1 basis in the past but now it is on a much more formal
2 basis, and we are very keen that the Trusts do not
3 suspend the doctor until one can look at it, unless
4 there is a major issue of patient safety and so forth.
5 Q. If I could just stop you there, it seems that there are
6 really two things perhaps. The first is that that is
7 consistent with the emphasis that you put at an earlier
8 stage upon local action and local solutions being the
9 first line of defence, as it were?
10 A. I think that is also the view of the General Medical
11 Council. I think anybody, as far as I know, anyone can
12 report a doctor to the General Medical Council, a member
13 of the public, you do not have to be medically
14 qualified. Their initial response is always the same:
15 to make sure any local initiatives have been dealt with
16 first, because that is the quickest and easiest way of
17 dealing with the problem. If that has been done and
18 there is still a problem then you can move it on. We
19 take the same view, to try and help the Trust, because
20 in many instances it can be resolved locally.
21 Q. The second point that arises out of that is that you
22 mentioned that you were very keen that the Trust should
23 not suspend the doctor unless there was a major issue of
24 patient safety?
25 A. I think everybody is taking the same view. The problem
0061
1 with suspension is, although in law and under HC 90, or
2 whatever the Department of Health rules are, it is
3 viewed as a neutral sanction. It quite clearly is not,
4 and particularly if it is a senior doctor, if you
5 suspend a senior doctor, there is no means of keeping
6 that confidential within a hospital. If the doctor is
7 reinstated, everybody assumes there is a problem which
8 is unresolved. It is better to address the problem than
9 allow things to go wrong with patient care. On the
10 other side, I think the doctor also should have some
11 protection, and suspension is not a neutral action from
12 the doctor's perspective.
13 Q. Turning back to the issue of accreditation, we have
14 discussed the use of the advice that can be offered to
15 local Trusts if there are particular problems of
16 performance. But what about the weapon of removal of
17 accreditation as a training centre? Has that been used
18 by the RCA?
19 A. Against a consultant who is not competent?
20 Q. Against the teaching centre as a whole.
21 A. Only if there are deficiencies in training. I do not
22 think we could use that sanction against an individual
23 consultant within that system. That would not be a fair
24 and proper thing to do, and we would almost certainly be
25 challenged on that, I am sure.
0062
1 Q. I meant as a matter of record, has the RCA ever acted to
2 remove designation or accreditation?
3 A. As a teaching hospital? Yes. I have to emphasize on
4 training issues, a number of teaching hospitals have
5 been removed. I do not think we have ever actually
6 removed them, but we have certainly threatened
7 deregulation on a number of occasions. What we do now,
8 we do not want any hospital to be derecognised, for
9 obvious reasons, because once that occurs, we have no
10 further influence there. What we now do is, if there
11 are serious training issues in a hospital, teaching or
12 otherwise, we meet with the Chief Executive and we say,
13 "Can we help you with a plan, so that when six months
14 or a year or whatever the time is has gone by, we will
15 not be back to visit you saying 'Nothing has happened
16 here'. We want you to succeed".
17 Certainly a number of teaching hospitals have been
18 put on threat of derecognition, and they have all
19 responded extremely well, and not surprisingly, because
20 it is a serious sanction.
21 Q. So you have used the threat, but the threat coupled with
22 such assistance as the College can give in devising
23 a plan and so on and so forth has been sufficient to
24 mean that you have not actually had to go down the
25 ultimate road?
0063
1 A. Absolutely right. I think you need to understand, if we
2 removed training accreditation from a teaching hospital,
3 it does not just affect that hospital, it affects all
4 the other hospitals in the school. We have 17 schools
5 of anaesthesia throughout the UK which can deliver our
6 training programme, based around one or more teaching
7 hospitals. So if we took out the accreditation of
8 a teaching hospital, the whole school will stop. So
9 they come under immense pressure, not just from their
10 own Trust but from all the surrounding hospitals. It is
11 a very serious threat and it has always been very
12 successful.
13 Q. If I could ask you to scroll down the page a little
14 further to paragraph 5.7, you say there that removal of
15 the privileges associated with college fellowship, such
16 as serving as an examiner, tutor or on College
17 committees, is currently restricted to those who fail to
18 remain in good standing, for example, by not paying the
19 relevant subscription.
20 How important or effective do you think that form
21 of sanction is to the clinicians concerned, if it were
22 to be utilised?
23 A. As it stands in the first sentence, of course, it
24 relates to a small number of people. We do not now
25 allow anybody, as it says there, to be an examiner,
0064
1 college tutor, serve on any college committees or
2 lecture on any college courses if they are not of good
3 standing. Most of the people who do that of course are
4 in good standing, and a reminder indicating that they
5 are not in good standing usually has a dramatic effect.
6 But that relates to a small number of fellows. At the
7 moment it is not a serious sanction. We are not sure
8 how many fellows do not pay. We think in the UK it is
9 a small number. There are quite a number of fellows
10 overseas who do not pay and there is not a lot we can do
11 about that. But within the UK we have tried very hard
12 to make sure everybody who is a consultant or
13 a non-consultant career grade doctor who has our
14 fellowship, we try and make them pay their dues and we
15 have a very persuasive Registrar who tries very hard to
16 do that.
17 Q. Are you saying in effect this sanction has only been
18 used against those who are not paying the relevant
19 subscription?
20 A. We have no other sanction against those, at the moment,
21 other than, as I indicated before the break, on the
22 CME. That is a voluntary requirement of all
23 consultants. Most consultants are involved in training
24 in some form, so somewhere down the line that will be
25 a sanction. But we think the future is in the
0065
1 revalidation. At the CME/CPD we would like the College
2 to set the standard for that, and part of that issue
3 would be that the fellow is in good standing with the
4 College, so the things are linked in that sense.
5 Q. Does that carry with it the implication that at present,
6 if you were concerned about the professional performance
7 of a particular clinician, this form of removal of
8 privileges would not be appropriate or a power even
9 available to the College, unless and until it had been
10 preceded by action by the GMC?
11 A. That is correct. I think if the College were concerned
12 about any individual practitioner, as I indicated
13 earlier on, I think we would put pressure first on the
14 Trust where they are employed, because that is the
15 quickest way of getting some action.
16 The difficulty with the GMC is that that takes
17 time, even if there is a serious issue. I am sure you
18 will reflect from the cases you are looking into now in
19 Bristol, it takes time, because of the law under which
20 the GMC operates, for something to happen.
21 Q. Can I press you on the relative efficacy of those two
22 routes. Would it not be your experience that in many
23 cases the response of the Hospital Trust might well be
24 that, particularly if the GMC showed any signs of
25 launching an investigation, the consultant in question,
0066
1 assuming it is a consultant, would simply have to remain
2 suspended or in any event the Hospital Trust could not
3 act, until the GMC had come to the end of its
4 procedures?
5 A. I agree with you, it is not straightforward, and that is
6 something which I suspect, with your Inquiry, and also
7 the issue of the consultants who have been suspended for
8 many years, that is now coming to a head and there are
9 going to be some changes in how that is done, because it
10 is obviously unsatisfactory at the moment.
11 I do not think in anaesthesia we have any
12 consultants who have been suspended long-term. They are
13 not in that group. There have certainly been
14 anaesthetists suspended and a small number reported to
15 the GMC, but the two methods are not straightforward.
16 One is operated through the Department of Health, one is
17 operated through the General Medical Council and it is
18 not ideal and it is very confusing to the outsider who
19 cannot understand why things do not happen. It is also
20 very confusing and depressing for the doctor, because if
21 they are suspended they are sometimes not clear why they
22 have been suspended and it is not easy for them to take
23 any action. We know that from doctors who have rung the
24 College for help, who find themselves suspended and do
25 not know what to do.
0067
1 Q. That is an answer which outlines, if I may say so, the
2 problem admirably. It is confusing; it may take a long
3 time; it is unsatisfactory. Can I ask you if you wish
4 to volunteer any solutions? Or is that too ...
5 A. I think that is why you are holding this Inquiry,
6 I suspect, or part of it. Well, it is not something
7 I could just do off-the-cuff, but what strikes me is,
8 I emphasize again, if you are worrying about a doctor
9 who is not doing well, working in a hospital, I still
10 think that has to be dealt with locally immediately,
11 because they are the only people who will know there is
12 an immediate problem. That suspension mechanism, I may
13 have the reference wrong -- HC 90, I am not sure --
14 whatever the mechanism is, that is a very confusing
15 document, it is not straightforward. Many Trusts do not
16 know quite how to apply it. We get involved through the
17 College because that mechanism asks for expert opinion
18 as well through what is called the Joint Consultants'
19 Committee and they then ask us for a representative. We
20 have sent people to those enquiries and it is
21 confusing. So that needs resolving.
22 Also I suspect that the GMC, when they come to
23 look at revalidation, will need to have the law changed
24 so that that process can work in a proper fashion,
25 because at the minute they have no legislation to do it.
0068
1 Q. If we could leave, then, the question of the pressure
2 exerted by way of teaching visits, you have referred
3 several times to the development by the RCA of
4 continuing medical education and now, perhaps,
5 continuing professional development.
6 If we look at page 4 of your statement, we see
7 there immediately, at paragraph 2.5, the endorsement --
8 I am looking at the last sentence of that paragraph --
9 of the proposals of the General Medical Council for
10 revalidation, and the generic document on revalidation
11 that has been more recently developed.
12 You say, however, before that, that it is not
13 compulsory to take part in CPD at the moment -- I am
14 looking at paragraph 2.4.
15 Are you able to help us on the numbers of those
16 whose subscriptions lapse after membership, after taking
17 the fellowship examination?
18 A. As I indicated to you, in the United Kingdom the number
19 of fellows of the College who do not pay a subscription
20 is very small and we pursue them vigorously. We have
21 a very aggressive Registrar in the College who writes
22 letters to fellows who do not pay, trying to encourage
23 them to pay.
24 We have a number of members overseas who do not
25 pay and they are difficult to pursue for obvious
0069
1 reasons. We believe the number is small, but they are
2 there. It is one of the things fellows periodically
3 threaten us with, along the lines, if we introduce any
4 more things that make life difficult for them, they will
5 not pay us any money, so they always have that option
6 that they do not need to pay.
7 Q. That is the position, then, on subscriptions: broadly
8 speaking, the English members of the faculty, the
9 College, keep theirs up.
10 What about on participation in continuing medical
11 education or continuing professional development?
12 A. Again, on the CME, as I indicated to you, when we do
13 a hospital visit, we look at every consultant's CME
14 points and the visitors make a particular issue of
15 asking about those consultants who do not appear to have
16 the points.
17 Again, I can tell you that the take-up is very
18 high. We have a few people who do not take it up, but
19 it is a small number.
20 Q. In percentage terms --
21 A. My guess would be about 95 per cent of consultant
22 anaesthetists are taking part in CME.
23 Q. And are obtaining the requisite number of CME points?
24 A. We take them on trust, they tell us they have done the
25 points and that is that.
0070
1 Q. That is the way of monitoring the extent of compliance
2 or participation in CME that has been developed since
3 1995?
4 A. Correct.
5 Q. What about the position prior to that?
6 A. Prior to that, there was no points system, and people
7 did whatever they thought was appropriate. Again,
8 I would have thought that a large number of consultants
9 were doing the things which would get them points now.
10 The points system was brought in to put a numerical
11 value on CME and it was based on what we believe the
12 average consultant would do to keep up to date. We have
13 to start somewhere.
14 I think it is fair to say, which everybody always
15 says, the relationship between having points and
16 competence, of course, is not proven.
17 Q. But if the general picture that has emerged in recent
18 years is that the vast majority do the right thing, but
19 there are a number who do not, is it fair to say that
20 that might have been the case back before 1995, but
21 there is no system to monitor it, so as to be able to
22 tell one way or the other?
23 A. That is correct.
24 Q. If we look, though, at paragraph 7.2, page 16, this is
25 a form of continuing education provided by the College
0071
1 itself, where you have set out the educational programme
2 for all grades of doctors.
3 Is there a danger that this sort of programme
4 might well be running foul of the danger that it simply
5 preaches to the converted: those who turn up are not
6 those you need most to reach?
7 A. We cannot force anybody to attend any of our courses,
8 obviously. You may well be correct.
9 Q. What about the scrutiny of consultants or practitioners
10 at the local level, because we have been talking about
11 the importance of trust and clinical scrutiny at that
12 level. Would employers have available to them, through
13 the period 1984 to 1995, better mechanics, or scrutiny
14 of continuing medical education?
15 A. I would not have thought so. I mean, Trusts introduced
16 money for study leave, and obviously they would have
17 a record of who took study leave, but that is a fairly
18 recent thing. I do not quite know when that began, but
19 my guess would be within the last 5 or 7 years, but
20 before that there was no record.
21 Q. I think studded through your documents, and we may come
22 to a reference at some point, there are references to
23 the difficulty of getting consultants to actually take
24 up that study leave and even if, say, 10 days has been
25 introduced as a study leave entitlement, there are
0072
1 problems in actual take-up of that?
2 A. I think that is true of many specialties. With
3 anaesthesia, of course, you have to be there to give the
4 anaesthetic, and if you are not there, somebody else has
5 to do it. So there are pressures on departments.
6 I think it is better than it was. Obviously everybody
7 cannot go away at the same time to a meeting or attend
8 keeping up to date, because there is nobody left to do
9 the clinical work. It has to cycle through. I think it
10 is better than it was and I think many Trusts now
11 understand it is part of their duty to ensure their
12 staff are up-to-date and go on a regular basis.
13 Q. It would be wrong to assume that if a consultant is not
14 taking study his or her study leave, that is the result
15 of any lack of inclination on their part. It may also
16 be a product of the pressures of work and the
17 organisation of the department that makes it difficult
18 to achieve?
19 A. The simple answer is it should not be, but what you say
20 in practice often happens.
21 Q. It is perhaps also fair to suggest, is it, that there
22 has been an evolution of approach or attitude towards
23 continuing medical education, or at least to
24 a formalisation of the requirements for continuing
25 medical education, over the period with which we are
0073
1 concerned?
2 A. I think that is correct. I think there is still
3 a certain cynicism in that it is perfectly possible to
4 obtain all the points and it have no relevance to your
5 practice. I think that is why everybody now, and we are
6 doing I think as well as anybody, is moving towards, not
7 calling it CME any more, but calling it CPD. The point
8 of that I think is that it has essentially two strands.
9 One is, we think that every anaesthetist should have the
10 core skills which you might reasonably expect them to do
11 if they are on an emergency call rota and those things
12 need to be cycled through on a regular basis to keep up
13 to date.
14 Then I think we need to have, the sort of current
15 jargon is a "personal portfolio", where it indicates
16 what the doctor actually does in their day-to-day
17 practice, the special areas, and how they are keeping up
18 to date, gaining new knowledge, in those areas.
19 The third part is that if they wish to embark upon
20 something new, how they are going to do that before they
21 start.
22 That has never been done in a formal fashion and
23 that is part of the work that we are currently doing,
24 for how we think anaesthetists should be re-validated in
25 the future, and we hope the GMC will accept that. We
0074
1 are about to start some pilot runs to see whether this
2 is feasible to do. When we talk to some of our
3 colleagues about personal portfolios, they look a little
4 anxious, and we need to make sure we can make something
5 work.
6 Q. From that point of view, could I ask you to turn to
7 page 553, which is the beginning of a document which
8 I hope is familiar to you, because it is the report of
9 a Working Party, and we can see from page 555, it is
10 dated July 1993, that you were in fact a member of the
11 Working Party that was looking at this subject.
12 A. Yes, I was.
13 Q. At page 556 the foreword appears. If we could just have
14 a look at the first paragraph:
15 "Increasing pressure on medical practitioners to
16 demonstrate publicly that they are subject to continuing
17 education and that it is of a suitable standard. It is
18 now almost two years since the Royal Colleges and their
19 faculties agreed to submit to the public domain their
20 current plans."
21 Looking at that as a member of the public,
22 perhaps, one might ask: why so long?
23 A. It is a good question. I think it was a totally new
24 concept to put it in writing. The two years were taken
25 up in debate with the Department of Health as to how the
0075
1 time and money was to be provided to do this, because
2 there had never been any allocation within the contract
3 of the consultant at that time for these activities.
4 I think that is where the time went by. I think
5 eventually all the Colleges, I think with the exception
6 of obstetricians who started a year sooner, decided that
7 we had to do it. So most of these CME programmes began
8 in 1995.
9 My recollection of it is that in that two years
10 there was debate as to where the time and money was to
11 come from.
12 Q. Yes, because it has funding implications?
13 A. It is not just the funding of the doctor to do these
14 things, but if they are not at their place of work, who
15 is to do the work while they are not there? So it was
16 a major step forward.
17 Q. If we go on to paragraph 2 of that document, the RCA
18 there notes the changing attitude of some fellows from
19 one of suspicion and uncertainty to increasing
20 acceptance that what most of us do anyway should be
21 placed within a formal structure of audit and
22 accountability.
23 Can you help us a little bit on the process by
24 which people have come to accept that need?
25 A. It is interesting; I think the people who object to this
0076
1 most and feel most threatened are often the ones who are
2 keeping up to date and doing everything you could wish
3 them to do. They feel, "Why do I have to justify this?"
4 I think that is part of the culture that has changed.
5 Those who are not keeping up to date and are not
6 interested are not the ones to complain and they just
7 hope it will not affect them. That is part of what that
8 reflects there.
9 But I think it has changed and I think doctors now
10 recognise that they have to justify what they are
11 doing. I would have thought the number of doctors who
12 do not believe that now is now the smaller number --
13 there will still be some, I am sure -- and most people
14 understand that there has to be some formal recognition
15 and demonstration. I think there is still anxiety over
16 this approach, we see it now with revalidation, in that
17 we have to come up with something which is workable,
18 doable, and it does not have enormous financial
19 implications, because otherwise it will not take place.
20 Q. How much assistance do you think has generally been
21 given to practitioners by employers at moving forward in
22 this direction?
23 A. I think there has been widespread variation. I think it
24 is one of the interesting things, when one does visits
25 on behalf of the College to Trusts, looking at training,
0077
1 the very wide variation there is. This is a function of
2 the independence of the Trusts, in that one can visit
3 two Trusts where the resources and facilities appear to
4 be similar and one is an institution where you feel,
5 "I would like to work there" and the other is one where
6 you feel you would rather not. This is a function of
7 the interaction between the managers and the doctors.
8 I think if you have a system of independent Trusts, that
9 is bound to help. One would hope they are all
10 improving, but some are doing better than others.
11 Q. The document then continues by summarising different
12 types of continuing medical education, and discusses in
13 particular, at page 557, at the bottom of that page, the
14 problem for anaesthetic practice compared to some other
15 branches of medicine, because it says there that
16 anaesthetists at senior level nearly always practice
17 alone -- and we turn over the page to get the rest of
18 that sentence, page 558 -- and there may not be a peer
19 from the speciality present.
20 Is that a comment that would apply to a teaching
21 hospital, or is it really directed at those in district
22 general hospitals or smaller centres?
23 A. I think it would apply to any hospital. It is
24 a function of a number of trainees, and the fact that
25 anaesthetics are commonly given by consultants without
0078
1 a trainee there, and also, of course, most anaesthetics
2 are given by one consultant, there is more than one
3 consultant present. There are some very complex cases
4 where occasionally there are two consultants present,
5 but that is rare.
6 Q. So that is why the solution of perhaps a joint list for
7 a month at a time, or a short period of time, to enable
8 some sort of consultation to take place is one of the
9 forms of continuing professional development that is now
10 under discussion?
11 A. That is absolutely correct. The other thing, we have
12 always encouraged departments to have departmental
13 meetings. It comes back to one of the questions you
14 asked me earlier. If you fragment the anaesthetic
15 department, you cannot hold those sorts of meetings.
16 That is why we have all been keen on there being
17 a department and that they meet together and can discuss
18 problems which one person may have seen and needs help
19 from somebody else.
20 Q. If we turn to page 562 and look towards the bottom of
21 the page, where the system of assessment is set out, if
22 I could just invite to you read the first paragraph, and
23 then the second I will pick up again. You say there
24 that the proposals are based on the premise that CME is
25 inherently a good thing. That obviously makes sense on
0079
1 an intellectual basis, but it has not been verified by
2 study yet.
3 Has, since this document was written, that
4 particular area been further explored and tackled?
5 A. We have of course published additions to this. This was
6 the base document put out in 1995 and there are some
7 further ones which I hope we have sent you copies of.
8 Q. Indeed, yes.
9 A. We issue updates periodically. I think we are trying to
10 move everybody on from the straight points system
11 towards the CPD, where the work that you do, the
12 updating you do, is related to your practice and to the
13 core topics, because we think that is more relevant than
14 just accumulating points on things which are not
15 specifically related to practice.
16 I think the clinical incident which is referred to
17 at the end of the second paragraph, we now have a series
18 of pilots running on the critical incident reporting
19 system, which I think we sent you copies of, and we
20 would hope that the Trusts will take that up on
21 a national basis.
22 Q. I think what I was trying to establish is that the last
23 paragraph on that page is really looking at the need for
24 an audit of the effectiveness of continuing professional
25 education and to establish, perhaps by way of hard
0080
1 financial criteria, the effectiveness of investment in
2 that area?
3 A. It is a very difficult thing to do, is my initial
4 comment. I think on the points system, there is no
5 evidence. Nobody has ever come up with any evidence,
6 other than -- and the reason in a way this whole thing
7 began -- that those doctors who do get into trouble, who
8 do appear in the courts or before the GMC, one fairly
9 consistent feature of many of them is that they have
10 clearly not kept up to date or they are engaging in
11 practice which is way outside anything that a body of
12 opinion would think was reasonable, and they are often
13 loners, the mavericks, the people who do not go to
14 meetings and so forth. It is not true of everyone, but
15 it is a significant factor, and that was one of the
16 forces that drove the Colleges and others to say "We
17 have to try and arrest this".
18 But it is an ongoing process; it is changing.
19 I think I would say that our thoughts on CPD may be the
20 way forward, so we can show some validity in the system,
21 but it is not an easy process.
22 Q. Do you think the difficulties of moving forward in this
23 area, in terms of establishing hard value-for-money
24 evidence for the effectiveness of continuing
25 professional development, make any difference to the
0081
1 difficulties of implementing such a system on the ground
2 with, say, the support of local employers?
3 A. Yes, there are obviously significant financial
4 implications. I think the other difficulty is that
5 there is a dilemma here. On the one hand, all the
6 things we have been talking about here relate to
7 quality, and as a principle, you could not possibly say
8 we should not have the best quality there is, regardless
9 of the cost.
10 On the other hand, there are those who think that
11 the system ought to be geared around picking out the
12 doctors who are doing badly. The two things are not
13 necessarily the same. The system of CME and CPD will
14 not in my view necessarily pick out the doctors who are
15 doing badly. You need to do something else for that,
16 and that is a slightly different approach.
17 Q. Why will it not function as a tool for identifying those
18 outside the system, the mavericks, the loners, who are
19 not turning up at the meetings, not updating themselves
20 regularly, and therefore it might be thought, at least
21 a priori, might be the ones where there are doubts over
22 their clinical competence?
23 A. Based on my experience in North America, I worked there
24 for ten years and they had in place many checks and
25 balances we are only now discussing in the UK. As you
0082
1 will know, I am sure, they have just concluded an
2 inquiry in Winnipeg in the children's hospital owing to
3 outcomes after cardiac surgery in children, and I think
4 some of that reads very similar to the Inquiry taking
5 place here. That part of the system will have many more
6 of these checks and balances in place. There has been
7 a requirement for years for consultants there every year
8 to demonstrate that they are up to date on everything,
9 et cetera, so in that sense, it did not pick this up.
10 Therefore, I think one would like to think, if you
11 raise the quality and standard everyone will go up and
12 no-one will be at the edges, but I think there will
13 still be people at the edges and you need additional
14 things to look at that, and that is quite complicated.
15 Q. Such as?
16 A. It is expensive and repressive, and doctors are quite
17 good at resisting that, as are all professional groups
18 in that sense. It is not impossible, but I just think
19 we are not necessarily all going in quite the same
20 direction on this thing. There are two separate things
21 here.
22 Some of this will come out I hope when the GMC
23 starts to look at how revalidation is being done. At
24 the moment they have made a commitment to do it but no
25 detail, and at the end of the day, they are one of the
0083
1 bodies with statutory powers and they will need to look
2 at that problem, but the two things in my view are not
3 absolutely synonymous.
4 Q. If we go back to your statement at page 6, at
5 paragraph 4.4 you set out there the support for the
6 development of the role of continuing medical education,
7 or professional development. There you set out the
8 attitude of the RCA towards statutory support, or
9 statutory responsibility for that area.
10 Can you tell us why you would see a statutory
11 validation of your role as being a useful tool?
12 A. I think what we are anxious about is that there be
13 a national standard and the College as a national body
14 for the United Kingdom for anaesthesia, we think we
15 could develop those standards.
16 What we are concerned about is that if this were
17 done at Trust level, or done by some other body,
18 specialist societies and so forth, it would not be
19 a national standard and it would not be as credible as
20 something which was. So that is our real concern.
21 We are of course consulting all our specialist
22 societies on the revalidation issue for their views on
23 this, so we can come together with a proper view. The
24 problem with specialist societies is that that is
25 exactly what they are: they take a very extreme view on
0084
1 certain things. They often make recommendations which
2 cannot be delivered, which may be ideals for the future
3 one should not ignore but cannot be delivered, and the
4 role of a national body like the College is to try and
5 bring all these together and say "Here is what we can do
6 now, here are the future goals we should go for, and it
7 will be the same wherever you go in the land". That
8 must be to the benefit of patients in the National
9 Health Service, that wherever they encounter an
10 anaesthetist, that person will be re-validated to the
11 same standard. The way of doing that is to have some
12 statutory responsibility, so if somebody does not wish
13 to do that, we can put pressure on them.
14 Q. Does that answer imply, in its emphasis upon the need
15 for national standards and the danger of either local
16 variations because of different hospital Trusts or
17 different pressures exerted by different specialist
18 societies, with perhaps conflicting objectives, does
19 that imply that at the moment there is a concern that
20 there are widespread variations in performance across
21 the country?
22 A. I think it does, because the Trusts at the moment have
23 no national standard. Clinical governance may begin to
24 improve that, but that is a local theme and the national
25 standards for that are not clear. We are just looking
0085
1 at a scenario where in Wales and Scotland health may
2 begin to have significant political interference and
3 there may be widespread differences. As a member of the
4 public, I like to think that if I go for an anaesthetic,
5 the anaesthetists, wherever they are, will be the same,
6 and preferably at the highest standard there is.
7 Q. It is apparent that the RCA has been working to try and
8 introduce national guidelines through a variety of
9 means, and one of them, for instance, was the 1994
10 Guidance for Purchasers, which set out in some detail
11 the sorts of standards to be expected in the variety of
12 anaesthetic departments right across any Hospital Trust.
13 What was your experience of the use made of
14 a document such as that in purchasing, in contracting,
15 after it was published?
16 A. I think the use was limited. It worked reasonably well
17 for some of the chronic pain services. The reason we
18 put out those documents was well expressed by the Audit
19 Commission. We thought that when the purchaser/provider
20 issues came up, most of them did not understand what the
21 role of anaesthesia was, and many of the contracts never
22 mentioned anaesthesia at all: no financial provision,
23 and they did not seem to understand that for some of the
24 contracts it was a very important issue. Many Trusts
25 did not quite understand, when that process began, how
0086
1 important it was that if they were contracting for
2 surgical services or intensive care medicine services or
3 whatever, there was a significant anaesthetic
4 component. That is why we wrote them. In that sense
5 they were useful. But that system has now gone and we
6 are into something new now. We are actually rewriting
7 them with a view pushing them towards the new general
8 practitioner groupings who will be arranging services,
9 again to point out to them that there is a quality issue
10 as well as a cost issue if they want to have good
11 anaesthetic service for whatever it is they are asking
12 for.
13 Q. So if that is right, did you see any influence or shift
14 in contracting between 1994 and the most recent set of
15 changes?
16 A. It would only be anecdotal. I think my impression is
17 that now Chief Executives of Trusts recognise how
18 important anaesthetic departments are in the running of
19 their Trusts. If one asks them "Where, on a scale of 1
20 to 10, do you place anaesthetic services?", most of them
21 will recognise that it is 1 or 2, because if they do not
22 have good anaesthetic services, they cannot run their
23 hospital. They still do not always like to pay for us,
24 of course, but that is nothing new in the National
25 Health Service.
0087
1 Q. If I could take you, perhaps, to your 1998 Good Practice
2 Guide, which is perhaps one of the most recent important
3 what one might call "standard setting" documents from
4 the RCA, that starts at page 134 of our documentation.
5 If you turn then to page 138 -- although I should
6 say, perhaps for the record, again, I think you were
7 a member of the Working Party that produced this, were
8 you not?
9 A. Correct.
10 Q. Then, at page 138, there is a foreword which sets out
11 its intentions. At the back, at the bottom, we learn
12 that it is hoped that it will enable anaesthetists to
13 put in place mechanisms which will promote the highest
14 levels of patient safety in anaesthetic practice.
15 Then page 139 sets out the background to the
16 production of this document, and it sets out concerns
17 being expressed by government, public bodies and the
18 media, about the continuing ability of doctors as
19 a whole to regulate themselves by setting, reviewing and
20 monitoring standards of care and ensuring compliance
21 with them.
22 Is that then the background of, as it were,
23 a political -- I use that with a small "p" sense --
24 attack or challenge to the mechanics of self-regulation?
25 A. I think that was part of it. The other reason this
0088
1 document was produced was that all specialist
2 organisations were being pressured to do outcome
3 studies, not least driven by the events here in
4 Bristol.
5 The difficulty we have in anaesthesia is that
6 there are very, very few patients who just get an
7 anaesthetic; they always get an anaesthetic in the
8 context of some other procedure. Therefore, when you
9 look at outcomes, it is sometimes quite difficult to
10 determine what is due to anaesthetic and what is due to
11 other factors.
12 We have always had, in anaesthesia, a very great
13 interest in the easy outcome, if you like, after
14 anaesthesia, which is death, because it is easy to
15 measure. In fact, anaesthesia started the original
16 confidential enquiries, the NCEPOD, although others now
17 think they thought of it first, but I have to go on
18 record and say that it came from anaesthesia. We were
19 the ones that wished to do this. Fortunately the number
20 of deaths directly due to anaesthesia in this country is
21 extremely low, which is good, but to come to your
22 question when asked whether we could measure outcomes
23 for anaesthetists, that is quite difficult to do. So we
24 went down the other route, which was to put together
25 this guide for departments of good practice, of good
0089
1 practice, things in the public domain which we thought
2 were being argued about, on the grounds that if
3 everybody followed this sort of practice, hopefully
4 things would not go wrong. So that was the logic behind
5 it.
6 Q. There might be seen to be a tension between this
7 document which says, "Look, we need to demonstrate
8 through the maintenance of standards such as these that
9 the profession can regulate itself", and the acceptance,
10 for instance in your witness statement, that a step
11 forward might be some level [and it is not complete] but
12 a level of statutory underpinning of the RCA's function,
13 in order to be able to enforce those standards?
14 A. No, I think the two things are related; I do not think
15 they are in conflict. This is not new. I mean,
16 I imagine the faculty and certainly the college has
17 always had requests for what the College's view is on
18 whatever it might be. To some extent we have been
19 a little anxious about being proscriptive from the top,
20 because if you do that and you are wrong or you suggest
21 something that cannot be delivered, you cannot get it to
22 work.
23 What you find in this document are only
24 guidelines, standards, which have been well-resourced,
25 well done; there is some evidence base for some of them,
0090
1 and we thought these would be absolutely acceptable to
2 the profession, to anaesthetists in general, and
3 therefore they were more likely to comply with them.
4 It is an ongoing process, as the end of the
5 documents says, and we are doing that, but we will
6 continue to try and implement this. We have moved on
7 now to the revalidation exercise which is part of it,
8 and we are also looking at how we are going to get new
9 guidelines when NICE is up and running so we can get
10 them accepted in the way any other guidelines should be
11 accepted.
12 Q. The suggestion that a measure of statutory underpinning
13 of the RCA's role would be useful suggests at least at
14 one level that there is some doubt as to the RCA's
15 ability, through persuasion, through influence, to be
16 able to deliver a standard application of these sorts of
17 guidelines across the country.
18 A. Well, we have tried extremely hard, but when you are
19 a voluntary organisation, you have limitations. The way
20 this was delivered was, we held a meeting (which was
21 unique) in July of last year of a representative from
22 every clinical department in the NHS which deals with
23 anaesthesia, to go over this document and see whether we
24 have support for it -- we did; there were detailed
25 issues on some of the words and so on, but we had good
0091
1 support -- and whether we would get people to sign up to
2 use it as part of clinical governance, which was
3 obviously just coming.
4 So in that sense, we had a lot of influence, but
5 we cannot say to people "You must follow this". When we
6 do visits, of course, we ask them whether they are
7 following it and if they say not, we say "Why not?", but
8 if we had some statutory powers, that would help. Not
9 everybody would wish us to have statutory powers, as
10 I am sure you will appreciate.
11 Q. To turn perhaps more to the actual standards set out in
12 the document, if we look at page 155, we are returning
13 there to the subject of continuing professional
14 education.
15 Over the page, at 156, there are set out the
16 various tools for continuing professional development
17 that could be used. They are obviously set out there
18 and I will not read them to you.
19 It may be that it is too difficult to try and push
20 back a document that was written or published in 1998 to
21 1994/96, but nevertheless the question I wanted to ask
22 for your comments on is the extent to which you think
23 that these tools were generally or at all in use in
24 hospitals across the country during that period.
25 A. If we look at the bullet points at the top, the only one
0092
1 that stands out which would not have been available are
2 anaesthetic simulators. They are not widely available
3 yet; they are coming. They were not available at that
4 time. I think most of the other things, not every
5 anaesthetist would have done them. They were certainly
6 available and some of them would have been doing them.
7 Q. "Available" means they are available as a tool, they
8 existed, unlike a simulator?
9 A. True.
10 Q. But the use of them: what was the sort of uptake?
11 A. I could not answer that question; I do not know.
12 Q. The same would presumably apply to the comment which
13 follows on at the next paragraph, the suggestion that
14 within a Trust, sharing an operating list once a month
15 with a consultant colleague may be of value?
16 A. Some would have done that, but I have no idea what the
17 uptake of that would be. Some people have done that
18 from the start and for years, but it would be on an
19 individual basis; I doubt it was widespread practice.
20 Q. If we turn back to page 141, the document at that point
21 deals with the system of regulation. It sets out
22 firstly an account of the different forms of regulation,
23 and secondly, it really sets out the RCA's guidance on
24 how best to go about invoking those mechanisms.
25 I think it is fair to say that perhaps emerging
0093
1 from this page and from the next -- do tell me if you
2 would like to take time to read them -- is the feeling
3 that local standard setting and regulation is the
4 important tool available to pick up problems with
5 performance?
6 A. I think as long as there is a national element to it,
7 yes.
8 Q. And the national element is?
9 A. We would like to think it comes through the college.
10 Q. In standard setting, you mean?
11 A. Yes.
12 Q. And presumably also the sanction of the GMC, if that has
13 to be invoked?
14 A. Yes.
15 Q. If we turn to page 142, Local Standard Setting and
16 Regulation, the paragraph there says that "the culture
17 in which doctors work is often not conducive to
18 admissions of deficiency which may be regarded as a sign
19 of weakness ignored or covered up. There is a gap
20 between central guidance and regulation and the
21 individual doctor, and the need to develop a sense of
22 corporate responsibility.
23 That general comment on the way in which doctors
24 function, the culture of hospitals: is that something
25 you would see as being a widely spread problem?
0094
1 A. Yes.
2 Q. By which you mean, what?
3 A. I think the first sentence certainly is correct: it is
4 changing, I think in the last probably two or three
5 years it is changing, but that was certainly the
6 position in hospitals for many years before that, and
7 unfortunately it is still the position in some hospitals
8 now.
9 Q. The references in the actual document to that particular
10 problem cite academic studies which were done between
11 1989 to 1995 -- I can take you to the references; it is
12 actually page 164, just to refresh your memory.
13 References 1 to 5 are the ones which are suggested to be
14 relevant to this cultural issue, as it were.
15 A. Yes.
16 Q. What you have there is a background of academic research
17 into the cultural features of how doctors deal with
18 problems, with mistakes, which is quite long-standing,
19 if it starts in 1989.
20 What about the recognition of these sorts of
21 factors on the ground? Would this be familiar territory
22 as a commentary on the way in which doctors worked in
23 most hospitals during the period from 1984 to 1995?
24 A. I would think so. Reference 5, Dr Lock was the editor
25 of the British Medical Journal, as was Dr Smith above.
0095
1 I think their views are quite correct.
2 There is a very good article in the Royal College
3 of Physicians just published recently by Dr Charlton on
4 the issue of accountability. He makes the point that we
5 actually have quite good systems within the National
6 Health Service for picking up doctors who are not doing
7 well, but we do not have any clear mechanism to deal
8 with them. That is the focus. I think his argument in
9 a sense was a bit against more revalidation.
10 One of the issues I was trying to express earlier
11 on is that that system will not deal with the problem.
12 What we need to face up to is how we are going to deal
13 with problems with doctors who are in trouble. That,
14 I think, is what is reflected in these references here,
15 that that is well recognised.
16 Part of your Inquiry here will be to try and
17 determine how that might be changed in the future, but
18 it is not easy in that it is a complex system and the
19 role of one individual is sometimes difficult to
20 determine.
21 Q. If we turn back to page 142 for a moment, if we may, the
22 point that is being made there is that the culture for
23 doctors is not conducive to admitting deficiency?
24 A. That is correct.
25 Q. And that that may be seen as a sign of weakness?
0096
1 A. That is absolutely correct.
2 Q. Is that something that was generally the case in most
3 hospitals across the period, or would you say that the
4 awareness of the criticism of this form of working made
5 some sort of impact on this whole problem, or not?
6 A. No, I think the first sentence is absolutely correct,
7 that being that the strength or weakness, whichever way
8 you look at it, of the National Health Service is that
9 the questioning of doctors was limited. I think you
10 have to understand, though, if you introduce a very
11 repressive system where you question everything, you
12 undermine the confidence of the individuals and they may
13 not do well because of that.
14 The point I was making earlier was where the
15 dilemma arises in terms of are you trying to raise the
16 standards or are you trying to detect the doctors who
17 are doing badly?
18 A lot of medicine is dependent on people being
19 confident and doing things where they may not have all
20 the information -- may never have all the information --
21 and particularly if you are dealing with patients who
22 are unwell. One of the difficulties in anaesthesia is
23 that you have to make decisions about a patient which
24 may influence the outcome when you do not have all the
25 information. You need confident people to do that.
0097
1 They obviously have to be well trained, but if they are
2 constantly in fear of somebody questioning what they
3 have done, you will undermine them and they may not be
4 able to function. So it is a two-way thing, really.
5 Q. Can I ask if there would be any particular difficulties
6 for anaesthetists as a discipline in challenging the
7 practices or difficulties that they had seen around
8 them?
9 The reason I ask that is that we have already
10 discussed the fact that the anaesthetist generally does
11 function as part of a team; they have an input in
12 a procedure involving a number of people. If we look
13 at, for example, a booklet called Stress in
14 Anaesthetists which was published in 1997, at page 1185,
15 that I think will give us simply the title page, if we
16 rotate it. It is a recent publication of the
17 Association of Anaesthetists of Great Britain & Ireland.
18 If we turn on to page 1191 and rotate it again,
19 there is a comment there under "Interpersonal", towards
20 the bottom of page 6. This is obviously a booklet --
21 I do not wish to take it out of context -- talking about
22 stress factors for anaesthetists, but it talks about the
23 interaction with surgeons, and then that that may be
24 a source of stress because of perceptions of
25 powerlessness and so on.
0098
1 Are there any particular dynamics within the role
2 of an anaesthetist which would make criticism difficult
3 to handle?
4 A. Yes, is the simple answer to that question. I think
5 a lot depends on the department in the hospital. There
6 are various arrangements where in some circumstances it
7 is and some circumstances it is not. In days gone by
8 departments of surgery and departments of medicine were
9 very powerful in the running of hospitals and hospitals
10 were often known as a 'surgical hospital' or
11 a 'medical hospital', depending on who held the
12 influence.
13 I think that has changed now in the current
14 management structures and often departments of
15 anaesthesia hold the power in that sense, but there are
16 always relationships and on occasion this may make life
17 very difficult. One works quite closely with one's
18 surgical colleagues, sometimes doing very difficult
19 things, and one can envisage all sorts of differences in
20 relationships there. I think that is what is issued
21 here.
22 I think it is better than it was in the sense that
23 anaesthetic departments have increased their power in
24 the system and if there is an obvious problem, one can
25 try and get the two people together and say "This is not
0099
1 going to work, can we solve it?", or re-arrange it or
2 whatever. But it still exists, I am sure.
3 Q. Presumably that is part of the reason behind the
4 recommendation that there should be a separate division
5 of anaesthesia, so as to give some sort of institutional
6 mechanism?
7 A. I think that is absolutely right. I guess there are
8 occasions when surgeons believe that they should control
9 everything around them, including their anaesthetic
10 colleagues, and that is an unhealthy arrangement in my
11 view because it always leads to strife in the end and is
12 a very strong reason for having a separate department.
13 Q. If we go on to the question of the ethical framework and
14 duties, again laid down by the guidance, towards
15 patients, page 144, this flips us back to the 1988 Good
16 Guidance.
17 There we have the ethical framework with the
18 changes in perhaps what one might call the absence of
19 deference, or the changing culture of deference, set out
20 at the beginning.
21 Then, towards the bottom of the page, professional
22 relationships with patients are set out.
23 They talk there about the need for trust and
24 confidence, courtesy, clear explanation, information,
25 written information for a patient, and then the duty of
0100
1 non-discrimination, which anaesthetists are obviously
2 under.
3 Then the last paragraph on the page: you talk
4 about how "if a mistake is made or a complication occurs
5 during the course of a patient's anaesthetic care which
6 affects outcome or may have implications for a future
7 anaesthetic ...", so perhaps one might say that perhaps
8 differentiates this case from a near miss, for instance,
9 where something perhaps might have happened but
10 nevertheless in the event there was no effect on
11 outcome, "... these must be discussed openly and
12 honestly with the patient and, where appropriate, with
13 relatives. This discussion should be recorded in the
14 patient's notes."
15 Was that a new obligation imposed in that
16 guidance?
17 A. I do not think so. It had always been there and of
18 course it is part of the GMC's guidance for doctors
19 which has been there for a long time. I think we spelt
20 it out here clearly for the first time, and certainly
21 the College supports the view that this should be done.
22 It is of some interest that the companies that
23 insured doctors before Crown indemnity came along
24 initially used to say you should not do this; you should
25 ring them up and ask for a statement. I think they have
0101
1 changed their view now. This was a commonly held view.
2 Anaesthesia potentially is high risk for medico-legal
3 considerations and as part of risk management, if
4 nothing else -- I think you should do it because it is
5 right; nothing to do with this nevertheless. Having
6 said that, there is a risk management issue here and one
7 may well avoid litigation if one does follow this
8 through.
9 One of the commonest reasons of course that
10 patients sue is because nobody told them what was going
11 on; they did not explain it.
12 Q. They feel they are kept in the dark?
13 A. That is absolutely right.
14 Q. What you are saying is that the ethical obligation to
15 admit to mistakes if they have affected outcomes or
16 might in the future, has been present all the way
17 through from 1984 to 1995, until the present day?
18 A. No, I would not say that at all. It was never done very
19 well. It has gathered speed. I think individuals did
20 it well, but overall it was not done well. I think it
21 is a difficult area.
22 Q. Can I stop you there, because that might mean two
23 different things. What I was seeking was some
24 assistance on the extent of the guidance that existed on
25 that, whereas what your answer possibly implied was that
0102
1 even if there was guidance, it might not necessarily be
2 followed by all.
3 A. I cannot tell you when the guidance began. To reflect
4 back again on my time in North America, this was part of
5 the culture when I arrived there in 1980, which was
6 a surprise to me because it was not part of the culture
7 when I left this country in 1980. What has happened in
8 the interim I do not know, but we are moving towards
9 this now and more and more people are doing it.
10 Q. You were in America from 1980 to 1990, is that right?
11 A. It was Canada, yes, but the law there requires you to do
12 this. It is not a requirement of law in this country.
13 The law there is absolutely clear -- there are major
14 differences in the law of consent there which we do not
15 have here either. There is a requirement in North
16 America that everything be disclosed to the patient in
17 initial meetings with them and alternatives explained
18 and so forth. That is not currently a requirement of
19 the law in this country.
20 Q. To what extent do you think we have succeeded in
21 implementing both the practice and the spirit of the
22 paragraph that we are looking at there?
23 A. I would have thought now that most Trusts, under their
24 risk management concepts, are busy doing this just to
25 protect themselves, apart from anything else. I say
0103
1 again, I think you should do this because it is right,
2 never mind all the other bits and pieces. The risk
3 management issue is of course pushing this very
4 carefully, because one way of avoiding lawsuits is to
5 follow what is in there.
6 Q. If we say Trusts are now doing that through their risk
7 management strategies, how far into the past can we push
8 that "now"?
9 A. I would have thought the Crown indemnity, particularly
10 when they moved to the CNST arrangements where they now
11 get a discount if they follow good practice, and this is
12 part of the good practice.
13 Q. Is there an issue about the interrelationship between
14 that duty and the need, or as it has been highlighted,
15 for confidentiality in audit?
16 If I look, for instance, at page 598, this is
17 from, if we take it down the page a little, this is from
18 the first report of the Audit Committee of the RCA.
19 Perhaps for the sake of completion, I should just ask
20 you to turn back to page 587 first, just to give us the
21 context. The first report of the Audit Committee,
22 November 1989.
23 Flicking forward again to page 598, which we were
24 looking at before, if we scroll down a little through
25 the page, please, to the heading "Audit and
0104
1 Confidentiality", there we see that "where case studies
2 are discussed at morbidity and mortality meetings, they
3 should not be identified for, in addition to ethical
4 considerations, such reports may have medico-legal
5 implications."
6 That is a summary of advice that has not really
7 changed throughout the years: that morbidity and
8 mortality meetings, audit data in general, is
9 anonymised, it should be made confidential, for
10 a variety of reasons including perhaps the litigation
11 one.
12 Is there any tension between those two approaches?
13 A. Well, there is, because people always feel anxious about
14 debating cases where something may have gone wrong, with
15 a view to what the medico-legal consequences might be.
16 I think what is stated here is correct and that
17 was in the document when we did it. I think there has
18 been a change since then, in that now, when we look at
19 our critical incident reporting system, we have the same
20 problems. That information comes to the College
21 anonymised because we are doing analysis for any
22 hospital that wishes to take part in it and we can
23 furnish them then with their incidents and they can look
24 at incidents from other institutions. That is
25 anonymised.
0105
1 Obviously within the institution it cannot be
2 anonymised; it is an event that has taken place and it
3 has to follow the risk management procedures of that
4 hospital. So there is some tension there.
5 To express a personal view, I am not aware of
6 anybody who ever got into difficulties by discussing
7 these cases properly, documenting them properly, as long
8 as it was factual as opposed to opinion. That will
9 always help you -- that is a personal view, not the view
10 of the College -- and it should be done.
11 There are others who do not take that view and say
12 everything should be anonymised, but you cannot now
13 anonymise a critical incident within the hospital; that
14 has to be reported. There is no way around that.
15 When we receive critical incidents to the College,
16 they can be anonymised because we are providing
17 information to other institutions, which is anonymous as
18 well.
19 I think it is an issue which is still to be
20 resolved, this question of anonymising critical
21 incidents, because my personal view is that they do not
22 need to be, but not everybody accepts that.
23 I think where one gets into difficulty is when
24 there are morbidity and mortality meetings within the
25 hospital where opinions are expressed about the
0106
1 performance of practitioners which may be incorrect. If
2 that is put down as a fact, obvious difficulties can
3 arise.
4 Q. A difficulty might be in a case in which opinions have
5 varied and that a morbidity and mortality meeting
6 expresses a range of views as to whether or not
7 a mistake has been made on some aspect of morbidity,
8 perhaps, not taking a mortality case.
9 Some practitioners take the view that a mistake
10 has been made and therefore under the guidelines we have
11 been looking at, would have a duty to report back to the
12 patient; others may take a different point of view. How
13 does one go about reconciling that situation?
14 A. I wish I knew the answer. Again, I go back to North
15 America: that was privileged information because they
16 had taken the view if you did not do that, you would
17 never get any discussion. I think here it is actually
18 discoverable -- you will correct me if I am wrong: if
19 somebody writes something down, as far as I know
20 anything can be discovered and therefore people are very
21 reluctant to do this.
22 I think that is bad and it is something that needs
23 to be addressed, because these cases should be
24 discussed, opinion should be stated and one wants to try
25 and find out what went wrong. But it is difficult
0107
1 sometimes. I think the risk management issues that are
2 coming now in the National Health Service will force
3 this, and I think at the end of the day they will not be
4 anonymised. I do not think they should be, personally,
5 but not everybody accepts that.
6 Q. We have strayed already on to the general topic of
7 audit. Just a few questions on that, before we come to
8 a close.
9 We are looking now at the 1989 report of the Audit
10 Committee. I think it is the first report of the Audit
11 Committee.
12 Arising out of that, a small correction, possibly,
13 to your statement. If we look at page 16 and go down to
14 paragraph 7.4, you say there:
15 "In October 1998 the RCA established a committee
16 currently known as the Professional Standards
17 Committee."
18 Should that be 1998?
19 A. That was when the Professional Standards was
20 established, but it followed on all the previous ones.
21 It has had various names as it has gone along.
22 Currently it is now called Professional Standards.
23 Q. As a committee looking at audit --
24 A. It goes back much further than that, yes.
25 Q. I wondered whether it might be 1988?
0108
1 A. No, I think we just changed the names, that is all.
2 Q. So you certainly had an Audit Committee up and running
3 by 1989, anyway, because we have just looked at its
4 report?
5 A. Yes, indeed.
6 Q. If we look at page 589, going back to that report, you
7 have there a committee which is having to set out
8 primary definitions of "audit", the very meaning of the
9 word. Did that reflect the novelty of the concept
10 within English medical practice at the time?
11 A. Yes, I think so.
12 Q. And secondly, if one looks a little bit further down the
13 page, there seems to be no general accepted definition.
14 It says "participants can demonstrate to themselves and
15 their colleagues ... the quality and quantity of the
16 work they are doing", and then it talks about entailing
17 an account of the use of resources and the outcome of
18 clinical practice.
19 What was the role of audit in what at the time
20 must have been, and no doubt still is, a very real
21 battle for resources for practice?
22 A. I think the difficulty with audit has been that we have
23 tried to do too much with it. We end up with very large
24 things where it cannot be delivered because, as you
25 rightly say, you need to make major changes in
0109
1 resources, and those are difficult.
2 I think the other problem has been that people
3 have not completed the so-called cycle; that they have
4 identified a problem, they have identified how it might
5 be dealt with, but they have not gone back to it and
6 said, "Has it been dealt with?"
7 A lot of time and energy has been spent on audit.
8 We have time assigned for it in most hospitals now;
9 there is a rolling audit time. What the College has
10 done now to try and get a better grip on this is that we
11 have put together an audit 'recipe book', which I trust
12 we sent you a copy of, to try and encourage people to go
13 for those things which can be done which will make
14 a change, and how they might do them, rather than some
15 of the more wider spaced things that can be done.
16 We also hope, of course, that clinical governance
17 now will get the attention of the Trusts and they will
18 have to deal with some of these, but of course some of
19 the major changes which audit picks up are resource
20 dependent, and many Trusts have just not been able to
21 deal with that.
22 Q. If we go on to page 590 of the document, it is apparent
23 that the committee at that time was collecting and
24 initiating ideas as to how anaesthesia could be audited,
25 and then the remainder of that page sets out a series of
0110
1 suggestions for the forms of audit that might take
2 place, if we can just scroll through that.
3 Then over the page, 591, if we go down a little,
4 please, to the morbidity and mortality audit, the
5 suggestion there is firstly that, as a recognition of
6 the importance of the national CEPOD study, which
7 I think has always been supported, as you said earlier,
8 by the RCA, and then, secondly that such meetings,
9 morbidity and mortality meetings, would be
10 interdisciplinary, involving the relevant medical and
11 surgical staff, and that anaesthetists would very
12 usefully be invited to attend surgical morbidity and
13 mortality meetings.
14 What was the norm throughout our period, if you
15 can help us, 1984/1995, towards the attendance of
16 anaesthetists at these forms of meetings?
17 A. I would have thought early on there would be individual
18 departments somewhere where this was occurring. What
19 the numbers would be, I do not know; it would be small.
20 I think the idea of the so-called rolling audit
21 days which Trusts introduced, where every month, usually
22 an afternoon (and on different days so it changes during
23 the time) is set aside so every clinical department is
24 doing audit. The idea of that was that you could hold
25 joint meetings. Certainly in the Trust I work in, we
0111
1 have done that, not on a very regular basis, but now and
2 again when a case comes up which obviously affects
3 a number of departments, we have put together a meeting
4 and said "Let us look at surgical histologies, x-rays",
5 whatever it may be, and try and get the relevant people
6 there. It is not an easy thing to do.
7 I think the reason that audit in a sense has
8 failed is that it was too ambitious to start with; there
9 were not always resources put to it. If you take an
10 individual case, people might come up with a solution,
11 but if it was something which implied resources, there
12 was not always an immediate response from the Trust and
13 I think people just got disheartened to carry it
14 through.
15 Q. If you say that audit in a sense has failed, that is
16 quite a general statement. Can you help us a little bit
17 as to why?
18 A. I think the reason is, as I say, it was too ambitious.
19 I think it focuses often on things which are resource
20 implications. The Trusts, with a few exceptions, have
21 not always been able to rise to this sort of challenge
22 and I think in that way the doctors just became
23 disheartened. They then focused down on smaller things
24 which could be done, and some of those have been very
25 good, but on some of the larger issues where you do not
0112
1 need an audit to establish there is a problem, the
2 Trusts, for various reasons, have been unable to deliver
3 this.
4 We are now talking about one of the things, for
5 instance in anaesthesia, which comes up regularly, is
6 providing clinical services on more than one site. You
7 can visit parts of the UK where common sense will tell
8 you that a hospital needs to be closed. There may
9 indeed be the resources to do that, but the political
10 will to do that is not always there, and things of that
11 nature. This is a very difficult problem. Audit can
12 pick that up every time, but you cannot solve it.
13 Q. Behind your answer lies an assessment of the impact, or
14 lack of it, that all the efforts to introduce audit have
15 had over the last five, six, seven, eight years.
16 Can you just help us as to the impact you think it
17 has made?
18 A. I think it has made some changes, clearly. I could not
19 quantify them for you. I am not saying we should not do
20 it; we should. I hope that clinical governance which
21 now says that Trusts have to look at quality as well as
22 financial implications will bring some of these things
23 up and there will be further changes taking place, but
24 it is an ongoing process and it can be very depressing
25 for people involved in it, because nothing appears to
0113
1 happen.
2 Q. Is that what you mean when you say that audit has been,
3 at least in some sense, a failure: the sense that all
4 the auditing has not necessarily led to a change in
5 practice, or in --
6 A. True, and I think some of the projects embarked on are
7 outwith the ability to do it. We do not have the
8 mechanism to do it.
9 One thing you are interested in is outcome. It is
10 actually very difficult to determine. We are embarking
11 next year on we think a fairly simple thing for
12 anaesthesia: we want to develop a denominator for the
13 number of anaesthetics given in the UK. We do not
14 know. We are not quite sure how we are going to do it,
15 but we are, in the Year 2000, going to have an attempt
16 to do at least a snapshot of how many anaesthetics are
17 given in the UK at any given time. You would think that
18 is fairly simple data you would need for any audit to
19 establish risk, but we do not have that information and
20 it is not going to be an easy task to do it.
21 Q. Different forms of audit have been touched upon in the
22 course of the morning, and obviously one of them has
23 been the critical incident register, or the 'near miss'
24 reporting. It is fair to say there has been a long
25 history of the involvement of the College with this form
0114
1 of work. In particular, you started first a pilot study
2 and now a national critical incident register, on which
3 you very kindly sent us further documentation.
4 Can I ask you: what would you think would be the
5 conditions for such a project being successful?
6 A. I think if everybody participated in it, it would be the
7 first step forward. It is a voluntary system and
8 clearly we want people to do it. There are pressures
9 and ways of making sure that anybody can report an
10 incident, and this puts pressure on the doctors to be
11 first, but we would like everybody to take part in it.
12 The other thing we would like, to make it
13 successful, is that people do not view this as
14 some punitive activity: that what we are trying to
15 establish is the incidence, where things happen; how we
16 might prevent them in the future. People would then not
17 feel that if they report something, they are immediately
18 going to be taken to task for it.
19 Q. Is that the reason, therefore, for the comment at
20 paragraph 8.4 of your statement, which is page 18,
21 where, in the last paragraph on the page, you say that
22 the principle of the pilot studies thus far is that all
23 data received by the RCA are anonymous and confidential,
24 and there are no means by which either hospitals,
25 patients or individual anaesthetists may be identified?
0115
1 A. I think that is correct. As I said earlier on, at the
2 end of the day I believe all of these will not be
3 anonymous or confidential, but that is up to the
4 individual Trust and their risk management to do that,
5 because these sorts of things need to be put in the
6 context of that particular hospital.
7 At the College we have reports from all sorts of
8 hospitals and we do not always know the context, so we
9 need to be cautious with the data and the
10 interpretation. One way of dealing with that is to make
11 it anonymous and confidential, so people would report so
12 we get as much as we can, and we can then look and see
13 what the pattern is across the hospitals, and so forth.
14 I think individual Trusts have to get a grip on
15 this and do it in proper fashion. There will be, as you
16 know, league tables; various clinical indicators are
17 going to be published in the coming year which relate to
18 death in hospitals and so forth, so that information
19 will be in the public domain and I am sure there will be
20 pressure to identify the individual doctors and patients
21 involved.
22 That has been an issue in the National CEPOD as
23 well. That originally was, and still is, anonymous and
24 confidential. Every time that is published there is
25 pressure to ask, "Which hospital?", "Which doctor?"
0116
1 Up to now that has been resisted on the grounds that if
2 that were to occur, there might be less people willing
3 to report. That also again, I think, needs to be in the
4 context of risk numbers, and that is why we are very
5 keen on having the denominator data, because we do not
6 have that for the National CEPOD.
7 Q. It is equally right, I think, that the RCA, or perhaps
8 the profession of anaesthetists in general, appear to
9 have had a long record of interest in the
10 standardisation of procedures, and have perhaps been
11 involved more than other disciplines of medicine, in
12 collaboration with things like the airline industry, at
13 developing such things as check-lists, and so on.
14 One can look, for instance, at page 1202 as
15 a simple example. This is simply the check-list for
16 anaesthetic machines. This particular edition was
17 published in 1990, but I think there have been a number
18 of them; is that right?
19 A. A number of ...
20 Q. A number of these check-lists.
21 A. Yes, indeed.
22 Q. If we look at page 1205 of this, we can see there --
23 I am looking at the third paragraph down -- there has
24 been collaboration between anaesthetists and the chief
25 pilot of KLM Royal Dutch Airlines to assess guidelines
0117
1 for, as it were, pre-operative procedures, just as
2 airline pilots go through these checks.
3 Can you comment on what it is about anaesthesia,
4 perhaps, that seems to have led to this form of
5 collaboration?
6 A. The airline analogy is often quoted. It is not 100 per
7 cent accurate. One thing is that, of course, every 747
8 looks like every other 747, and regrettably, all of our
9 equipment is different.
10 The other thing of course is that we are dealing
11 with patients, all of whom are different, and in
12 addition, it must be a pretty rare experience for a 747
13 pilot to discover somebody sawing through the controls
14 of the plane while he is trying to fly it, whereas, when
15 I do an anaesthetic, there is a surgical operation going
16 on which may interfere with what I am trying to do.
17 So the analogies are there, but they are not quite
18 the same.
19 Certainly, some of the check things, where there
20 is a clear protocol and there is only one way of doing
21 it -- obviously one of the key things of flying
22 aeroplanes is to try and persuade pilots to always do it
23 the same way -- for certain anaesthetic things, of which
24 checking the machinery is one, it is clearly the same
25 and that is why we have done it. That has been
0118
1 successful. The number of things going wrong now which
2 relate to machine failure, equipment failure: that is
3 a very rare event in anaesthesia now. It used to be
4 common. It has gone down dramatically. Regrettably,
5 things still go wrong with the performance of the
6 anaesthetist, but the cases where a piece of equipment
7 has failed or it has not been checked properly or
8 whatever is a credit to the manufacturers of the
9 equipment, as well as a checking system such as this.
10 Q. Is it implicit in your answer that really the airline
11 analogy has gone as far as it could: that where there
12 are opportunities for the standardisation of procedure
13 those have been taken, either in the discipline of
14 anaesthesia or others, or is there still more work
15 waiting to be done?
16 A. The other thing which is now coming across, which is
17 very relevant in the airline industry, is the use of
18 simulators. The airline industry has shown that you can
19 train people to fly an aeroplane by training them on
20 a simulator. We do not think we can train people to
21 give an anaesthetic on a simulator, but we can certainly
22 train them in managing crises, in managing rare events
23 which they may never see in their training but when they
24 become a consultant they may have to manage; how to
25 manage a team of people, those sorts of issues. Those
0119
1 are now starting. The number of simulators in the UK,
2 there are currently two, one in Bristol, one in
3 Scotland; there are two more coming into London now and
4 one in Northern Ireland, so things will be growing.
5 Certainly the experience in North America, where there
6 are most of these, is that you can train people to do
7 crisis management, team management and those things, so
8 in that sense it is analogous to the airline industry.
9 I doubt if we are yet anywhere near the stage of
10 actually training somebody to give conventional
11 anaesthetics. We may one day, but not yet.
12 Q. So still further directions to be explored, perhaps,
13 through the use of simulators.
14 It is clearly one thing to produce guidelines for
15 the equipment, check-lists and so on. To what extent
16 have such guidelines, if produced, been properly used
17 throughout the anaesthetic world?
18 A. I think the equipment ones have been quite good. Again,
19 it is a responsibility of the Trust as well as the
20 clinical department that when somebody new starts they
21 have a proper initiation; if a new piece of equipment is
22 introduced, that you follow the Health and Safety at
23 Work Act -- I think that is the legislation that covers
24 it; that you make sure that people do it.
25 I run an academic unit and if we introduce any new
0120
1 piece of equipment in the laboratories, everybody who is
2 going to use it has to show that they have read the
3 instructions and have been trained on how to use it
4 before they use it.
5 Those check-list things, I think, have been quite
6 well implemented.
7 Q. Thank you, Professor Strunin. I have asked a number of
8 questions throughout quite a long period of time. Can
9 I ask you this: is there anything that you would like to
10 say to the Inquiry today that has not come through in
11 the discussion we have been having throughout the
12 morning? I emphasize, there is no necessity that it
13 should come today; we are going to be here for a while.
14 If there is anything you would like to add at this
15 moment, perhaps you would like to do so?
16 A. One thing, as I indicated to you, we will look at all
17 the visits to the BRI and if there is anything relevant
18 I will draw your attention to it and send you copies of
19 all of that. I am sorry that we do not have it here
20 today.
21 The only comment I would make, which I have done
22 and will just re-emphasise, is that since this Inquiry
23 began and previous other events, the Colleges have come
24 under a certain amount of attack that they are not,
25 quote, 'delivering' on assessing competence and all
0121
1 these other issues. I emphasise again, we do not have
2 any statutory power. We are a voluntary body. We have
3 statutory powers over trainees and over the appointment
4 of consultants. We have a lot of pressure we can apply
5 on keeping up to date and so forth, but at the moment,
6 we do not have any statutory powers over the consultant
7 who is not performing well. I think that still is the
8 responsibility primarily of the local mechanism, the
9 Trust, the Clinical Director of the Department, the
10 Medical Director. The College is willing to help with
11 doctors to see whether we can advise the Trust, and at
12 the end of the day still the General Medical Council is
13 the regulatory body.
14 Q. If you do not have those statutory powers -- and you
15 make the point very clearly that you do not -- is your
16 comment a plea to be given them, or merely a statement
17 of existing reality?
18 A. It is partially existing reality, because, as I say, we
19 come under attack and I think people do not quite
20 realise that we cannot do what they would wish us to do.
21 I emphasise again, the College would wish to have
22 the statutory power to set the standard for the future,
23 which would be mandatory in some fashion, either
24 regulated through the Trust's employment or through the
25 GMC. The reason for saying that is that we believe we
0122
1 could deliver a national standard throughout the UK so
2 it would be the same. It would have to be done locally
3 to make it feasible and we need to come up with
4 something which is workable and practical, but we think
5 we are the body to do that. That is what we would like
6 to do. We would like to have some statutory power and
7 if the doctor does not do that, we can say, "You are not
8 doing [this]. Now we have to move to the next stage to
9 deal with it."
10 Q. Is this power which you would like to possess something
11 you have asked for?
12 A. We are certainly making representations to the Academy
13 of Medical Royal Colleges, to the General Medical
14 Council, not just for the College of Anaesthetists but
15 for all colleges. We had a very recent meeting with Sir
16 Donald Irving to make that very point: that we believe
17 that the Colleges are the bodies to deliver the
18 standards -- not the sanctions; that is the matter for
19 the legislation and the General Medical Council will
20 need to get legislation to deal with that. But to say
21 what the standard is, we could deliver that.
22 MISS GREY: Thank you very much, Professor Strunin.
23 MISS GREY: Sir, this may be a moment either for
24 a convenient break, or alternatively for questions from
25 yourself or from other members of the Panel.
0123
1 THE CHAIRMAN: I think there are some questions from the
2 Panel, although not very many. I would rather we take
3 them now than have another break if we may.
4 Mrs MacLean?
5 EXAMINED by the PANEL
6 MRS MACLEAN: Thank you. I think my question follows on
7 from the discussion you have just been having with
8 Miss Grey.
9 I am interested in how the College's response to
10 a doctor in difficulty is triggered. Perhaps you could
11 clarify for me.
12 It seems from your written statement, you are
13 describing how the Joint Liaison Committee will respond
14 to a request for help about the performance of an
15 individual doctor, and that is clear. That is
16 a reactive response; you cannot initiate it.
17 When it comes to looking at performance of the
18 doctor as capable of providing a proper training
19 position, proper support, there your involvement is much
20 more active; you are going out there to see whether
21 everything is well and there are things you can do if
22 you are concerned.
23 Is it that there is a difference between
24 performance as clinician and performance as educator, or
25 is it the difference between dealing with the doctor as
0124
1 an individual and dealing with the training situation as
2 an organisational entity? Or something of a mixture?
3 A. We have more experience, of course, about training
4 because we have been doing that longer. I think there
5 are organisational issues there we look at. We look at
6 the training, we look very carefully at the comments the
7 trainees make about the trainers, which is a good way of
8 finding out what the trainers are up to. That is
9 a confidential interview. The mechanism there is fairly
10 well-developed. I think we are reasonably good at
11 that. We have quite good things in place for training
12 the people who do that. We try and be consistent with
13 visits -- we have not always been consistent but we are
14 trying to make them consistent, and we try to focus on
15 training issues.
16 If I give you an example, one of the difficulties
17 we have, for instance -- it is a common complaint still
18 in some hospitals -- is that there is no hot food at
19 night or the accommodation for trainees for call is
20 bad. You can be sympathetic with that --
21 THE CHAIRMAN: May I ask you just to slow down? It is so
22 important that we capture your answer. If you could
23 just go a little more slowly?
24 A. I am sorry. The relevance of that to the performance of
25 the doctor and the patient care and so on is sometimes
0125
1 difficult to establish.
2 So that side of things is quite good.
3 We have not had clear mechanisms, as I was trying
4 to indicate, for looking at the activity in its broadest
5 sense of the people who are not trainees. We should,
6 but we do not have, within our charter, within our
7 mechanisms, within the law as it is, any real means of
8 doing that, and yet everybody, I think, believes that we
9 do. That is why we feel a bit defensive on occasion.
10 We would like to do it, but we are going to have to do
11 in it a manner which is consistent with the bodies which
12 currently have the sanctions, which are the Trusts and
13 the GMC.
14 That is really the point I was trying to make.
15 That, I think, is about to change now. We are very keen
16 to do it because we think we represent all anaesthetists
17 and we can do it.
18 Does that answer your question?
19 MRS MACLEAN: Yes, thank you.
20 MRS HOWARD: Professor Strunin, I just have a few
21 questions. The first question I would like to ask is,
22 when you talked at some length about the College's view
23 that they would wish to have statutory powers to impose
24 national standards, what I have not heard this morning,
25 and perhaps you could explain again to me, is the
0126
1 College's view on your responsibility for actually
2 policing those standards which you would wish to
3 impose. I would be happy if you could clarify the
4 College's view on that.
5 A. We are trying to develop it along a number of lines.
6 One is that the individual doctor would have a personal
7 portfolio of their activities divided into the core
8 competencies and their special interests.
9 Secondly, we believe that the Department they work
10 in should have a portfolio to show that they are doing
11 all the administrative things they need to do, so that
12 that doctor can do his work properly. That would have
13 to be done in some way that it can be reviewed.
14 The problem is that there is a cost to that and
15 there is a time element to that, and we are looking at
16 something which has to be deliverable. We cannot have,
17 I think, a scenario where everybody goes and inspects
18 everybody else and nobody is doing the work, because
19 that is one anxiety one has.
20 That is not fully developed yet, but we are
21 looking at running some pilot schemes during the summer
22 in a number of departments. Some we believe are very
23 co-operative; we are trying to encourage a number who
24 are not co-operative, who do not think it can be done,
25 to see where the problems lie so that we are ready
0127
1 towards the end of this year, when I hope every College
2 to the Academy will be making representations to the
3 General Medical Council as to how this might be
4 delivered.
5 This is still changing. Not everybody believes
6 the doctors should be self-regulating. Not everybody
7 believes the Colleges can or should do this. So we are
8 in a sense in an area of competition at the moment. We
9 want to convince people that we can do it.
10 Q. So are you saying that the College's view at this stage
11 is that you would be wishing to determine some statutory
12 power for policing the standards that you would wish to
13 impose?
14 A. I do not like the word "police". We are not the
15 "police".
16 Q. I apologise for the use of the word.
17 A. I think what we, the College, would like to do is that
18 we would deliver the standard and some means of
19 assessing whether or not the doctor has met that
20 standard. If they have not, that is where the 'police'
21 element comes in. That is something which clinical
22 governance plus the GMC needs to develop, as to how that
23 is to be done. That is the mechanisms whereby those
24 doctors who are not complying are helped in the first
25 instance, if they can be, and if they cannot be helped,
0128
1 they should not be practising.
2 There is also the issue of the guidelines which
3 will come from NICE and the Commission for Health
4 Improvement which will come round, so there is
5 a potential for an awful lot of inspection and
6 addressing which obviously, if it is done badly, will
7 not work and the whole scheme will be discredited. We
8 want it to work, so we want to play our part in it.
9 Q. Thank you. Two very short questions.
10 When you talked about the teaching visits, if an
11 individual anaesthetist had a concern, would it be
12 unprecedented for them to approach the visitors as
13 opposed to going through the clinical tutor?
14 A. No. It happens on occasion. It depends, obviously.
15 It would be more likely to be a training issue. I think
16 I would be disappointed with that, obviously, because we
17 want people to go through the tutor, but it does occur
18 and that is the reason for meeting with the
19 consultants. If they wish to raise a matter, we would
20 hope it would all come through the tutor. Usually, if
21 an individual is going around the whole system, it
22 indicates there may be a serious problem and one would
23 have to look at it very carefully.
24 Q. When you say one would have to look at it very
25 carefully, would you take that as an indirect training
0129
1 issue?
2 A. I think it would depend what the issue was that the
3 person raised, is the answer to that. If it related to
4 training, the visitors need to take it seriously.
5 Obviously, if it is an individual who has a totally
6 different view from everybody else in the institution,
7 you need to take that into account, to put it into
8 relevance. That occurs with any group of people. If it
9 was a serious issue, we would take it seriously.
10 I think we have to.
11 Q. Thank you very much.
12 A. Just to answer your question a little further, the
13 visitors make a report to our Training Committee, so
14 there is another group of people who look at it who may
15 well know the hospital and can make comment on the
16 visitors meeting, and then it has to come to the Council
17 to be ratified, because they are the group who take the
18 ultimate responsibility of writing back to the hospital
19 saying they can or cannot train.
20 MRS HOWARD: Thank you.
21 THE CHAIRMAN: Professor Jarman?
22 PROFESSOR JARMAN: I just want to ask one question, which is
23 related to the thing you have emphasised about the need
24 for statutory powers and the fact that the inspections
25 for training are really one of the major positive
0130
1 things, and also taking it in the context that you did
2 some visits and so far you have not found any problems
3 at the BRI in your search.
4 Miss Grey pointed out to you that there had been
5 some questions raised about the standards there, and in
6 fact, one of the anaesthetists had raised it with
7 Professor Pryce-Roberts in 1989 and 1992. I think he
8 became the President of your Royal College in 1994.
9 That was a setting in which the possibility of some
10 problems had been raised.
11 The Royal College of Physicians did a visit in
12 1992 and they reported the other day -- this is from
13 Professor Alberti -- that there were problems with
14 excessive workloads, such that it was probable at times
15 that the quality of patient care may fall below
16 standards. In fact, there is actually a letter,
17 UBHT 247/183, which is from the anaesthetist at the BRI,
18 Dr Monk, who was Clinical Director there. On the next
19 page, actually, is his name. As you will see at the
20 top, that is to Mr Wisheart, who is the Medical Director
21 of the Trust.
22 On the next page , the letter is concerned with
23 the fact that the waiting list initiatives are causing
24 difficulties and that the junior medical staff involved
25 will be exceeding their newly imposed 72 hour limit,
0131
1 i.e. reduced from 100 or whatever it was to 72.
2 So obviously it is with a background where
3 problems have been expressed. There is a report from
4 one of the visitors for inspecting training posts, from
5 the Royal College of Physicians. This might have raised
6 some questions. You were also doing visits as well.
7 Was there any co-ordination? This could have been
8 helpful.
9 A. No. This is one of the criticisms of the College
10 visits, of course: there is no co-ordination. I have to
11 say now, if we encounter serious anaesthetic problems,
12 our visitors are instructed to ask the Medical Director
13 whether they have had a visit from any other College
14 recently, because often there are problems in other
15 specialties. The Medical Director does not always wish
16 to tell us that, of course, which is a problem.
17 There is no co-ordination at the moment. That is
18 about to change as well, because it is obvious that
19 visit after a visit is unsatisfactory, and there are
20 some moves to see whether these can be brought together.
21 The issue you raise here is interesting, and I will
22 certainly look through the paperwork to see whether that
23 is reflected in any of the anaesthetic ones. But it may
24 not be.
25 Q. Just as a rider, do you think some formal method of
0132
1 co-ordination could be helpful and practical?
2 A. I think it would be helpful. The practicalities of it
3 are not quite as straightforward as might be. There is
4 also of course the role of post-graduate dean, and some
5 of the things we look at in visits we are going to
6 devolve to the post-graduate deans. Our college, and
7 I suspect others will do the same, would wish to reserve
8 the right to visit anyway, because of course the
9 post-graduate deans may also find themselves compromised
10 on occasional issues and we would wish to come as an
11 outside body and look at that specifically.
12 PROFESSOR JARMAN: Thank you very much.
13 THE CHAIRMAN: Thank you. Professor Strunin, I have no
14 questions, so may I, on behalf of the Panel, thank you
15 very much for making time to come and give evidence
16 today. We have been much instructed. I re-emphasise
17 what Miss Grey has said. If there are other matters
18 that occur to you that you would wish to let us know,
19 please do so.
20 You have undertaken to have a further search to
21 see whether there are materials which particularly touch
22 upon visits to Bristol as regards training, and we would
23 be very grateful if you were able to do that and let us
24 know the result of your searches.
25 For the moment at least, thank you very much.
0133
1 Miss Grey?
2 MISS GREY: Professor Strunin, thank you very much indeed.
3 THE CHAIRMAN: Mr Langstaff, I will detain Professor Strunin
4 for just two seconds more, please.
5 MR LANGSTAFF: Sir, it has become the convention that at the
6 end of each day I tell you what is going to happen
7 tomorrow, to give a sneak preview, not so much to you
8 but as to the waiting and interested public.
9 Tomorrow we will hear from Sir Michael Carlisle,
10 who was the Chairman of the Supra Regional Services
11 Advisory Group. You will recall that last week we heard
12 witnesses: we heard from Mr Gregory, Mr Angilley,
13 Mr Owen and Dr Halliday, all of whom, from their
14 different perspectives, gave evidence about the
15 operation and effect of the Supra Regional Services
16 Advisory Group. This week we will hear not only from
17 Sir Michael, tomorrow, but also from Sir Terence
18 English, whose name cropped up in particular in the
19 evidence of Dr Halliday. He will be on Thursday.
20 I wonder if I may just take a moment, though, to
21 say, by way of some apology and explanation, that it has
22 been the custom (as you know but, again, the waiting and
23 interested public may not) that when witnesses are going
24 to be called their statements are circulated some time
25 in advance, so that those who have comments to make
0134
1 which would be helpful to us in asking questions can do
2 so.
3 May I pay tribute to the several representatives
4 (many of them have not been apparent in the chamber, but
5 that does not mean to say they have not been working
6 hard and we have not been benefiting from the fruits of
7 their labour) who have indeed passed us information and
8 useful suggestions as to the areas that might assist
9 you, the Panel, in coming to your conclusions.
10 My apology, after that somewhat lengthy
11 introduction, is simply that this statement has come
12 rather late in the day so that it is available now. May
13 I just say to those who might have been hoping to have
14 it earlier, that it is one of those things: we have it
15 and we have it as best we can, but I am sorry if it has
16 put anyone at disadvantage in getting information to us
17 in the usual way.
18 THE CHAIRMAN: Mr Langstaff, I am grateful to you. I echo
19 the thanks you expressed and would like it to be known
20 that we are very much helped by the observations which
21 are fed in to you and thereby fed through to us, so I am
22 happy to endorse that.
23 Sometimes statements obviously will be slow
24 coming. It is a matter of regret that that is the case,
25 but we will on this occasion have to live with it.
0135
1 We will meet tomorrow morning at 9.30, but now we
2 adjourn for the day. Thank you.
3 (14.32 pm)
4 (Adjourned to 9.30 on Tuesday, 11th May 1999)
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9 I N D E X
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12 PROFESSOR LEO STRUNIN (Sworn)
13
14 EXAMINED by MISS GREY ........................ 1
15 EXAMINED by the PANEL ........................ 124
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001