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Daily transcripts
Hearing summary
17th May 1999
Professor David Baum, President of the Royal College of Paediatrics and Child Health
(RCPCH) and Professor of Child Health at the University of Bristol, came to give evidence
today. Professor Baum described the evolution of the RCPCH from the British Paediatric
Association to its establishment in 1996 saying that its aims were a child centred service
which would provide seamless co-ordinated delivery and planning of healthcare for
children. He outlined major developments which had taken place over the period in terms of
standard setting and monitoring and continuing medical education for senior clinicians. He
was questioned about referrals from GP to paediatrician, from paediatrician to
cardiologist and on to paediatric cardiac surgeon. He said that several factors would be
taken into account in deciding where to make a referral: geography, professional
diagnostic skills, family circumstances and rarity of service. He said that he would have
felt that if a unit was designated to provide a service, it should mean that the service
was of an acceptable standard. He went on to say that it would be useful for physicians to
have a database of hospital performance, but that this was not available during the
Inquiry’s terms of reference. The issue of the facilities at Bristol was discussed,
and he said that the location of the paediatric cardiac services being split between two
sites was not ideal, but not unique to Bristol. As a member of clinical staff at the
Bristol Children’s Hospital he said that he had never heard any criticism of the
paediatric cardiac service on the hospital ‘grapevine’. On the contrary, he said
he had heard positive comments about the Children’s Heart Circle and the appointment
of a counsellor and excitement about the proposed concentration of the paediatric cardiac
surgical services on one site.
Today the Inquiry concluded the evidence from Sir Terence English, former President of
the Royal College of Surgeons of England (RCSE) and member of the Supra Regional Services
Advisory Group (SRSAG) 1990 – 1992. Sir Terence told the Inquiry last week that he
had received a request from Dr Norman Halliday, Medical Secretary of SRSAG in July 1991 to
arrange a RCSE review of the infant and neonatal cardiac service, asking for
recommendations about whether, firstly, some surgical procedures could be omitted from
supra-regional status and secondly if some units should be de-designated. He said the
report recommended that the number of designated units be reduced, de-designating
Harefield and Guy’s and designating Leicester. In between receiving the report and
the July meeting of the SRSAG, Sir Terence confirmed that he had received a letter from Dr
John Zorab, Medical Director at Frenchay Hospital, forwarded to him by Professor Norman
Browse, the new President of the RCSE. He said the letter expressed serious concerns about
the quality of paediatric cardiac surgery at Bristol. Sir Terence said that he revisited
the RCSE report and was concerned both by the emerging trend that activity figures were
falling, and that mortality figures for Bristol were high. He said he discussed amending
the report to include Bristol amongst the units to be de-designated with the Chairman of
the Review Group Professor David Hamilton, who agreed to the change. He said he then
advised Dr Norman Halliday of the revised recommendation and asked him to convey it to the
next SRSAG meeting, for which Sir Terence had to send his apologies due to an annual
holiday. Subsequently, Sir Terence told the Inquiry today, that Professor Hamilton further
discussed the change with other colleagues from the Royal College and decided to reverse
his decision and to leave Bristol as a designated unit, he went on to inform Dr Halliday
of this decision by telephone before the SRSAG meeting. Sir Terence confirmed that SRSAG
in his absence decided to de-designate the entire service and to ignore the
recommendations of the RCSE report. He said he attended the September SRSAG meeting with
the hope of being able to change this outcome, but was unsuccessful in this. This was his
last attendance at a SRSAG meeting. Sir Terence confirmed he had not passed on his
concerns about mortality at Bristol to the Department of Health or Regional Health
Authority, assuming instead that Dr Halliday, to whom he had expressed his concerns, would
take the matter further. In 1995, Sir Terence said he wrote to Dr Roylance, the former
Chief Executive of the United Bristol Healthcare Trust (UBHT) expressing his concern that
Dr Dhasmana, consultant Cardiothoracic Surgeon, had been restricted from undertaking
paediatric work following the internal inquiry commissioned by the UBHT. He said that the
internal inquiry had identified no problems with Mr Dhasmana’s competence. He
concluded by affirming that comparative data for surgical success would be helpful to
surgeons, especially when assessing their own performance.
In order to complete the evidence of Sir Terence English today, the Inquiry hearings
sat until past 5.00p.m. Therefore the transcript will be published on the Inquiry website
tomorrow morning.
|
FULL TRANSCRIPT
1 Day 18, 17th May 1999
2 (10.08 am)
3 THE CHAIRMAN: Mr Langstaff, perhaps I should begin by
4 apologising; we are 10 minutes late and we do seek to
5 adhere to our timetable, but sometimes there is a need
6 for last minute conversations outside between various
7 lawyers and parties. I understand this, but I would be
8 anxious if we can, to the best of our ability, adhere to
9 our timetable
10 ADDRESS TO THE PANEL by MR LANGSTAFF:
11 MR LANGSTAFF: Sir, if I may, for my part, begin the week on
12 a note of impertinence: I hope that at some stage we may
13 manage between and us the computers to ensure that all
14 our watches are on the same time. We do not make it
15 quite 10 minutes, if I can put it that way!
16 Sir, I wonder if I may just pick up two or three
17 issues which arose at the end of last week? In part,
18 arising from that which Mr Lissack was telling the
19 Inquiry on Thursday evening.
20 May I, for my part, pay tribute to the way in
21 which the Bristol Heart Children's Action Group has
22 co-operated. Indeed, I am glad to hear that Mr Lissack
23 and the Group feel the same about the assistance that
24 they have had from counsel, as do Counsel to the Inquiry
25 in response. But one may have perhaps detected from
0001
1 what he was saying some underlying feeling that the
2 parents whom he represents, and no doubt others whom he
3 does not, may feel that they have had their say in this
4 Inquiry already; nothing, as you know, is further from
5 the truth.
6 The Inquiry works principally on written material,
7 written statements which are presented to it. The oral
8 evidence is a supplement to it -- important, but
9 a supplement. It is vital to the work of this Inquiry
10 that we go on receiving statements from those who can
11 assist.
12 What we have in mind, those of us who present the
13 evidence to you, the Panel, is that we would hope to
14 call parents, not only when we come towards the end of
15 the Inquiry, Blocks 5 and 6, when we explore the
16 concerns that were raised in respect of the Bristol
17 surgery in the 1990s, but earlier, in June, next month,
18 when we hope to explore the issues relating to the split
19 site, about which we anticipate many parents, both from
20 the Heart Action Group and from the Surgeons' Support
21 Group, and those several others who are members of
22 neither, may have something to say. Secondly, the
23 highly emotive issue of retention of tissue, which we
24 hope to explore at the moment in July, is the tentative
25 timetabling for that.
0002
1 As of this morning, the Inquiry has had 16
2 statements from the Heart Action Group and 19 statements
3 from the Surgeons' Support Group, but that, I suspect,
4 is only the tip of what I hope I do not wrongly describe
5 as an "iceberg", because we know from questionnaires
6 already submitted to the Inquiry that a further 97
7 members of the Heart Action Group have indicated they
8 are prepared to give statements, as are a further 20 of
9 the Surgeons' Support Group. We have in addition
10 received questionnaires from 94 parents who apparently
11 are members of neither group, and yet who are willing to
12 give statements.
13 The Inquiry has written to all of those parents
14 asking them to state whether they wish their statement
15 to be taken by the legal teams or the Heart Action Group
16 or the Surgeons' Support Group by their own solicitor or
17 by the legal team from the Inquiry. We are awaiting
18 replies to some of those letters. Some are coming in,
19 and I shall report the outcome in due course.
20 Can I just take this opportunity to encourage,
21 publicly, through the electronic means we have at our
22 disposal, anyone who wishes to formalise their
23 questionnaire, or indeed, who wishes to make a statement
24 who has not yet been in contact, to do so, because the
25 Inquiry is keen to go on receiving as much information
0003
1 as possible.
2 Can I, with that said, turn in something of the
3 same vein to the first of two allegations which were
4 made in the course of Mr Lissack's address on Thursday
5 last, when he told the Inquiry that the Secretary of
6 State had been told at a meeting in April 1998 by his
7 clients that they strongly suspected a cover-up
8 involving the Royal College of Surgeons of England, the
9 Department of Health and the Bristol Royal Infirmary,
10 and he indicated that that remained their view.
11 In the spirit of co-operation which has
12 characterised the relationship between the lawyers for
13 all parties and Counsel to the Inquiry, I have asked him
14 whether there is any evidence which he had which had not
15 been sent to the Inquiry. There is not, so far as I can
16 gather, but what I would like to say is this: that
17 plainly the allegation is a serious one; it comes from
18 a responsible and respectable source and deserves to be
19 treated seriously, so can I take this moment to ask
20 again, through the electronic media we have at our
21 disposal, that anyone, whether in the Department of
22 Health, whether in the Royal College of Surgeons,
23 whether in the Trust or elsewhere, who has any
24 information which will enable the Inquiry to determine
25 whether there may or may not have been a cover-up such
0004
1 as is alleged, to come forward and to let us, at the
2 Inquiry, have that information. If that individual is
3 not happy to speak directly to the Inquiry, then I would
4 encourage that person to speak to his or her solicitor
5 and his or her solicitor will no doubt, as one would
6 expect, forward the information on to the Inquiry. But
7 we are keen to hear, because we, for our part, take
8 seriously the promise that no stone will be left
9 unturned.
10 I would hope that any information provided will
11 condescend to details of who, when and how, but I have
12 to leave that, of course, for the individual concerned.
13 Secondly, an allegation -- I am not sure if it was
14 an allegation; that may be too strong a word -- but the
15 complaint was made by Mr Lissack that there had been
16 correspondence with the Secretariat of the Inquiry about
17 the possibility that there might be cross-examination,
18 and he told you, sir, that he had seen correspondence to
19 and from the Inquiry which states that you have been
20 aware of the specific detailed, reasoned and written
21 concerns over cross-examination since last October.
22 I am told by him that the letters to which he
23 refers are dated respectively 26th and 29th October.
24 I have asked that they be looked out, and they consist
25 of a letter of 26th October(page 1, 2, 3), written by Tozers,
0005
1 solicitors, addressed to Miss Charlotte Martin, the
2 Assistant Solicitor to the Inquiry, and her reply that
3 I have dated, 30th October, in response.(page 1, 2)
4 What I propose to do, what arrangements will be
5 made to do, is to put those on the Internet because in
6 essence they will speak for themselves and the public
7 are entitled to see what the position was and is in
8 respect of those concerns, so that we, in the Inquiry,
9 deal with things in it without putting a spin upon it,
10 so those who may wish to know may see the raw material
11 for themselves.
12 Can I confirm that it is right that he, on behalf
13 of his clients, advanced a protocol as to
14 cross-examination and when cross-examination might be
15 permitted. This was in March of this year. There were
16 discussions about it which we, for our part, thought had
17 been resolved -- resolved in the sense that the protocol
18 was acknowledged, but it was asking for more than the
19 Inquiry were prepared to give, because it went beyond
20 that which you said in your opening statement last
21 October.
22 That is the history of the matter. As to the
23 principles, it is not my position to address the Inquiry
24 because it is for the Inquiry to make its position clear
25 if it wishes to do so. Sir, it may be helpful if you,
0006
1 on behalf of the Panel, were to make a short statement
2 as to the principles that inform the view that was taken
3 as to cross-examination.
4 May I, as part of my function as Counsel to the
5 Inquiry, advise that nothing should be said which in any
6 sense should be seen to prejudge or predetermine, or
7 prejudice, any application which Mr Lissack may yet make
8 to cross-examine Sir Terence English, or others, because
9 they must plainly be dealt with on their own merits, so
10 it is only to the general question that you may wish to
11 address some remarks
12 CHAIRMAN'S STATEMENT:
13 THE CHAIRMAN: Mr Langstaff, thank you. I crave the
14 indulgence of our first witness, because I am going to
15 speak for a few minutes, I am not sure how long. I hope
16 you will forgive me for doing so and not calling -- I am
17 now addressing the witness who is sitting here --
18 forgive me if we do this and it causes you to wait
19 a little while.
20 As you say, Mr Langstaff, I do want to make some
21 general remarks in the hope that they may be of some
22 help. Though they be specifically initially addressed
23 to Mr Lissack, because it was he who raised a number of
24 questions, of course, to the extent that they are
25 helpful or relevant to others, I would ask others to
0007
1 give them appropriate attention.
2 The Panel, I and my colleagues, think, Mr Lissack
3 in particular, that it may be helpful in view of the
4 intervention on Thursday to share some of our thoughts
5 again concerning the shape and the form of this
6 Inquiry. You, for your part, shared with us on Thursday
7 what you described as some "dissatisfaction" amongst
8 your clients. We recognise that there are many strong
9 feelings and high emotions about the matters we are
10 looking into, for the Panel as well as for others, and
11 they are always there. Every time we walk into this
12 hearing chamber, we are reminded again of the tragedy
13 which brings us here. We acknowledged this on the first
14 day of the public hearings back in October, and it is
15 with us every day as we sit, as we read and as we sift
16 evidence.
17 But you will also remember that by our very use of
18 the word "tragedy" on that day in October, we were
19 accused of bias, of having prejudged matters. Of
20 course, we did no such thing. We defy anyone, as
21 Mr Langstaff said in his opening address back in March,
22 to deny that the death of or injury to a child, however
23 it is caused, can be anything other than a tragedy. We
24 cannot take a view on what may have led to those deaths
25 and injury, that is in part what we are here to
0008
1 discover, but we can and do acknowledge the tragedy.
2 Equally, it is a tragedy that after 10 or 15 years
3 we are in this room, still trying to understand what
4 went on, such that so many people cannot get on with
5 their lives.
6 Thus, there was no bias in October, but equally,
7 not everyone may accept this. This is because, and it
8 is a trite observation is but no less true, different
9 people hold different views.
10 We ask, therefore, that everyone appreciates the
11 Panel's dilemma. We do not forget for a moment the
12 grief, the pain, the frustration and, yes, the anger of
13 your clients. But once the Inquiry has begun, we must
14 be even-handed and fair to everyone who gives evidence.
15 We must assume, as a starting point, that each witness
16 deserves the same respect. We cannot set out to subject
17 a particular witness to, as it were, the third degree.
18 Leaving aside the fact that such an approach usually
19 produces more heat than light, it is plainly unfair. It
20 assumes in advance both that there has been wrong-doing
21 and that this witness is a wrong-doer. The Panel makes
22 no such assumptions; we cannot. We began this Inquiry
23 with a clean sheet. We will read and hear the evidence
24 in as impartial and fair a manner as we can.
25 Conclusions are to be drawn at the end.
0009
1 So we ask again that you understand our position,
2 just as you ask us to understand yours. To proceed as
3 we do does not diminish for a moment our sense of
4 tragedy, but it is the only way to deal fairly with all
5 who appear before us.
6 We say this directly to you, Mr Lissack, and
7 through you to your clients. Whatever its history, this
8 Inquiry now belongs to the public. We cannot defer to
9 any individual or group. All who appear before us are
10 entitled to and will receive a fair hearing.
11 Of course, we on the Panel recognise we are asking
12 from you and your clients, just as we are asking from
13 everyone else, for two things that are probably the
14 hardest to give: trust and patience; trust that we will
15 see things through, and keep our promise to get to the
16 bottom of things.
17 As for patience in such a complex Inquiry as this,
18 understanding takes time. We will be hearing evidence
19 in this room until December. Of course this may be too
20 slow for some, particularly those who are impatient for
21 us to reach a particular view, but we must read and
22 listen carefully and this takes time.
23 So we ask for patience. We will do our duty in as
24 timely a manner as we can.
25 Finally, in the, as it were, 'conversation'
0010
1 between you and me, a request for guidance on
2 cross-examination was, as Mr Langstaff said, made before
3 Easter. We did not then believe that it would be
4 helpful to issue the requested protocol. The criteria
5 had been set out in October and any application could
6 then be made. We were, and remain, anxious that the
7 procedure which we believe is proper for this Inquiry
8 should not become lost in ever denser legal thickets.
9 That said, we are now persuaded that some guidance
10 as to the process to be followed may be of some use and
11 for that reason, we, the Panel, will issue guidance
12 today.
13 Having offered these general observations, may
14 I go on to say something about cross-examination, and
15 again, I crave your indulgence. Clearly any decision,
16 as Mr Langstaff properly reminded us, must await both an
17 application and the Panel's consideration of it. But we
18 thought it might be helpful if we set out the context in
19 which applications will be considered.
20 We have to consider any application for
21 cross-examination against the background of the
22 procedure we announced in October, and have reaffirmed
23 on a number of occasions. We, the Panel, recognise our
24 procedure may cause concerns to some; indeed,
25 Mr Lissack, you and I crossed swords early on concerning
0011
1 re-examination, when I was anxious to make clear at the
2 outset that we intended to follow our declared
3 procedure. As I said at the time, I meant no offence.
4 If I was too zealous or too harsh in affirming my
5 remarks, I regret that and I am sorry.
6 Now the issue is not re-examination; it is
7 cross-examination. There are some, including perhaps,
8 and especially, perhaps, legal representatives, who may
9 feel that we can never get to the bottom of things
10 unless we allow the legal representatives of all those
11 who are interested in this Inquiry to bring their
12 forensic skills to bear in exposing witnesses to
13 cross-examination. After all, this is what happens in
14 courts, and we have grown familiar with it elsewhere,
15 too.
16 Well, we have said many times, this is not a court
17 and we are not judges. We have been chosen for our
18 expertise in other fields: in medicine, in nursing, in
19 management, in university research and in health, law,
20 ethics and policy.
21 So we do things our way, within the general
22 framework of the law, of course. We are conducting
23 a Public Inquiry, an Inquiry which is hugely complex,
24 which is not concerned with a single event but spreads
25 over 12 years and hundreds and hundreds of events, and
0012
1 which is concerned as much with policy and culture as it
2 is with practice.
3 Our duty is to serve that public interest, not the
4 interests of any particular section. Our brief is,
5 quite frankly, humbling, ranging from the events at
6 Bristol to making recommendations for securing the
7 highest quality of care across the NHS, and to do all of
8 this in a timely fashion.
9 We were convinced in the outset and remain
10 convinced that the only proper way to fulfil our public
11 duty is to adopt an inquisitorial procedure. We were
12 and are convinced that the adoption of adversarial
13 positions will not ordinarily help us in our tasks. We
14 venture to believe that the story of Bristol and of the
15 NHS in the 1980s and 1990s will emerge more fully and
16 clearly if we are able to avoid the confrontations and
17 the often illusory black and white clarity which
18 adversariness tends to bring.
19 There are a couple of other factors to bear in
20 mind: first our procedure relying on written statements
21 and comments means that matters calling for
22 clarification can be clarified by further written
23 submissions. It is eminently flexible. Secondly, the
24 fact that this phase of the Inquiry will take many
25 months means that there is less need, indeed, little
0013
1 need, for instant comment and response; a feature,
2 indeed, some may say the feature, of cross-examination.
3 As I said on Thursday, let no-one fear that
4 because something which warrants challenge is not
5 challenged at that very moment, it will remain
6 unchallenged.
7 Much of the work in this Inquiry is in reading
8 that which has been written. What has been written is
9 not limited to the evidence; it includes comment.
10 Indeed, the Surgeons' Support Group has already
11 submitted a lengthy comment on the conclusions which we
12 should draw from Block 1 of our evidence. We regard
13 this as most helpful, whatever view we may take
14 ultimately of its content.
15 It is equally open to any participant in the
16 Inquiry to submit to us similar comments on any block,
17 or on what any witness has said, or for that matter, has
18 not said. We can assure you that whatever is submitted
19 will be read and will be considered fully, and of course
20 it will be published.
21 It is sometimes said that cross-examination is
22 comment dressed up as questions. To the extent that
23 there is any truth in that, such comment can be made in
24 writing.
25 Thus, even if one door, that leading to
0014
1 cross-examination, may on any particular occasion be
2 closed, we hope we are being constructive in reminding
3 legal representatives that there are other doors which
4 are always open.
5 We realise our general approach may disappoint
6 some. Indeed, there are some who may understandably see
7 this Inquiry as, at last, the opportunity to bring
8 someone to account and that cross-examination is a vital
9 tool in that process.
10 Well, the Inquiry does provide that opportunity
11 where it is proper to do so, to bring people to account,
12 but we do not see adversariness as a necessary tool to
13 achieving this. It does not mean that our examination
14 will not be rigorous or thorough. The Inquiry's
15 counsel, helpfully, if I may pay tribute again, aided by
16 other legal representatives has demonstrated this.
17 Further, as I repeated on Thursday, let no-one think
18 that because we set our face largely against an
19 adversarial approach, we are inevitably committed to
20 writing a report which in some way will lack force or
21 bite. Let no-one be in doubt that when we come to write
22 our report, if tough things have to be said, they will
23 be said. We read, we listen, we build up our
24 understanding, and we strive to treat all who appear
25 before us with equal fairness.
0015
1 Finally, let no-one think that our procedure, as
2 I repeat it again, and as Mr Langstaff made clear in
3 March, makes legal representatives redundant; far from
4 it. They have a crucial role, but it may be one which
5 is largely behind the scenes, although no less important
6 for that.
7 Our repeated reminder that we are not a court, we
8 accept, we understand, may cause some to chafe. They
9 may wish us to proceed by other perhaps more familiar
10 rules. We understand this, but we have set out our
11 procedure frequently. We first announced it in
12 October. It is not merely appropriate but essential if
13 we are to meet the obligations placed on us by the
14 Secretary of State in a proper and timely manner.
15 So it is against this background, and I thought it
16 important to rehearse it at some length, that we will
17 consider any application, but I remind all here that of
18 course any application that is made must and will be
19 considered on its particular merits.
20 Mr Langstaff, I have gone on perhaps rather longer
21 than I had hoped, but now may I defer to you?
22 MR LANGSTAFF: Sir, yes. I shall be short. Professor Baum,
23 would you come forward, please? Miss Grey will take his
24 evidence.
25 MISS GREY: Professor Baum, I am sorry you have been kept
0016
1 waiting, but I trust you will understand the need for
2 the debate we have just had. As you will also know, the
3 evidence in this Inquiry is taken on oath, so can
4 I invite you to stand and take the oath?
5 PROFESSOR DAVID BAUM (Sworn):
6 Examined by MISS GREY:
7 Q. Could we have, please, on the screen, WIT 36, page 1?
8 This is the title page of a statement which has been
9 written by you, but represents a consensus amongst
10 elected senior officers of the Royal College of
11 Paediatrics and Child Health; is that correct?
12 A. That is correct.
13 Q. You, of course, are the current President of that
14 college?
15 A. I am.
16 Q. Can I just ask you as a matter of record: are the
17 contents of the statement that we see there true?
18 A. The opening statement is true and it is the beginning of
19 the full statement, that is true.
20 Q. Professor Baum, you are firstly a Fellow of The Royal
21 College of Physicians of London?
22 A. Firstly, in chronological terms.
23 Q. And secondly, a Fellow of The Royal College of
24 Physicians of Edinburgh?
25 A. Correct.
0017
1 Q. Also, perhaps, in chronological terms?
2 A. Not quite, but let us not complicate matters.
3 Q. And thirdly, of course, you are a Fellow of The Royal
4 College of Paediatrics and Child Health?
5 A. I am.
6 Q. And its President. You are also, I think, the Professor
7 of Child Health at the University of Bristol?
8 A. I am.
9 Q. When did you take up that post?
10 A. On August 15th at 11.30, 1985.
11 Q. Is it right there that at the University of Bristol your
12 main concern has been to build up the University
13 department under your control and guidance?
14 A. It has been my main concern.
15 Q. And also to build up, to develop, an Institute of Child
16 Health?
17 A. That is so.
18 Q. But it is also right, is it not, that you are in fact
19 a clinician at the Bristol Children's Hospital, holding
20 a particular interest, a specialty in the field of
21 diabetes?
22 A. That is correct. I am a general paediatrician in
23 clinical practice with a special concern for childhood
24 diabetes.
25 Q. So you have some involvement and knowledge of the
0018
1 Children's Hospital at Bristol since 1985?
2 A. I have.
3 Q. And although you have come to speak to us on behalf of
4 the Royal College of Paediatrics and Child Health, it
5 may be that at odd times this morning your evidence will
6 also touch upon your knowledge of that hospital; is that
7 right?
8 A. That would seem to be a proper ...
9 Q. Thank you. Professor Baum, I think it is the case that
10 you may need to speak a little more loudly. I do not
11 know that the microphone needs to come any closer; it
12 does pick up sound from a distance of about 3 metres,
13 but it still needs a fairly clear statement before it
14 picks it up adequately.
15 A. Thank you.
16 Q. Turning back to the Royal College of Paediatrics and
17 Child Health, it is right that the College has been
18 a late arrival to the group of Royal Colleges and that
19 its charter was not awarded until 1996?
20 A. That is correct.
21 Q. It follows, therefore, simply as a matter of record,
22 that the College has not had responsibility for the
23 accreditation of hospital training posts in the field of
24 paediatrics during the period from 1984 to 1995?
25 A. That is correct.
0019
1 Q. You will appreciate, of course, that the period I have
2 just described is the period of our terms of reference
3 as an Inquiry.
4 A. That is so.
5 Q. It is of course the case that now that position has
6 changed and the College has taken up that function,
7 together with other associated functions such as such
8 aspects as continued education for its members and also
9 a role in the appointment of hospital consultants,
10 paediatricians?
11 A. That is so, but if I may just offer a gloss on that, of
12 course as you have read in our full statement, there was
13 a gestation before our birth and during the years,
14 indeed, the decades, and particularly the latter ten
15 years before the birth of the College, we were exerting
16 considerable influence, at least upon the ethos of
17 quality of clinical practice.
18 Q. Because the predecessor to the Royal College was of
19 course the British Paediatric Association, a membership
20 association that in some respects attained the status of
21 a college even prior to its recognition as such in 1986?
22 A. Exactly so.
23 Q. Could I ask you, however, Professor Baum, about the
24 status in which the profession of paediatrics and the
25 discipline of paediatrics was held during the period of
0020
1 1984 to 1995? Does the late recognition, if I may call
2 it so, of the Royal College of Paediatrics and Child
3 Health as such lead you to make any comment on the
4 general status of the profession of paediatrics during
5 the earlier period, that period?
6 A. It does. It is not of course unique to this country.
7 Across the world the independent voice of paediatrics
8 has been later than physicians and surgeons as an
9 identifying group in the world of medicine. In the
10 United States the separation of the American Academy of
11 Paediatrics was quite late in coming into existence, and
12 in this country, much later still was the separate
13 identity of our profession as deserving of a Royal
14 College of its own.
15 If one has to understand that, I think as you will
16 see from our document, it is really well put in the
17 context of the United Nations Convention on The Rights
18 of the Child. That itself did not come to the world
19 until 1989 and that was a recognition in the world in
20 a much broader sense: that children are a group without
21 a vote who are biologically heterogeneous, have rights,
22 are fully formed humans, albeit at an immature stage and
23 that there is this very broad case for recognising
24 children as a separate entity, and we, as physicians for
25 children, made our case that in this country that should
0021
1 be reflected by a separate voice on equal standing with
2 physicians, surgeons, anaesthetists and so forth.
3 Q. It is, I think, a comment made in the evidence of the
4 Royal College of Nursing that the UN Convention on The
5 Rights of the Child was ratified by this country in
6 1991. Would that fit into the general historical
7 pattern that you have just been describing?
8 A. I think the point on the graph is exactly well placed.
9 Q. If we turn from that statement to the Royal College of
10 Nursing, this is WIT 42. If I can invite you to put up
11 page 6, please. If we can just scroll down to the
12 bottom of that page, this is a historical perspective on
13 the development of health services for children, and if
14 I could just invite you to read paragraph 2.5 at the
15 bottom of the page:
16 "Advances in the knowledge of children's physical,
17 psychological and physiological needs took place during
18 the early decades of this century. However, government
19 acceptance of the separate needs of children who are ill
20 or have a major disability was only recognised for the
21 first time with the publication of the Platt report in
22 1959."
23 Would you agree with that paragraph?
24 A. I would, but would regard it as an understatement,
25 because -- if I may just divert for a moment, the early
0022
1 part of my career in the middle 1960s to middle 1970s
2 was the period when the even more separate identity,
3 physiologically, biologically, of the new-born baby was
4 being described, and those descriptions, that
5 developmental physiology in which many of us found our
6 early career, portrayed differences much greater than
7 the differences which were at that time recognised, at
8 the time of the Platt report. So whatever was stated
9 there, with which I would associate myself most
10 strongly, applies, and applied decade by decade, more so
11 with the uncovering of the huge biological differences
12 of the new-born and prematurely born.
13 Q. Would it be fair to say, therefore, that the insights
14 that the Platt report offered were overtaken by events,
15 and seen to recognise or to reflect a fairly limited
16 understanding of the separate needs of the child?
17 A. I would agree with that.
18 Q. If we could just turn over the page to page 7 and look
19 at the first paragraph, 2.6:
20 "There have been difficulties in establishing
21 a true recognition of the status and value of child
22 health professionals."
23 Then the statement goes on to talk about the
24 emphasis on adult nursing, meaning that children's
25 nursing has not been accorded equal professional status
0023
1 over the years.
2 It continues:
3 "The development of the professional status of
4 children's nursing which has been mirrored with medical
5 colleagues and paediatricians only achieved the status
6 of a Royal College in 1996, with the formation of the
7 Royal College of Paediatrics and Child Health."
8 Is the thrust of the argument set out in that
9 paragraph something you would endorse, or something you
10 would wish to disagree with in any shape or form?
11 A. No, I would endorse it. It is difficult to concisely
12 portray a view of what is behind it, but elements of
13 what is behind it, if I may look to the Panel, forgive
14 me for turning my back as I speak, are matters that in
15 the self-selection of what branch of medicine doctors
16 and nurses choose to go, there are, of course,
17 determining factors, and it would be the case that,
18 putting myself aside from what I am about to say, one
19 might consider that those choosing to go into the
20 medicine of children might have a gentler approach to
21 life, a more listening and sympathetic approach to life,
22 and prior to the physiological and scientific explosion
23 of the latter half of this century, that led to
24 a certain avuncular, sentimental at times, reputation,
25 and I think that, while appropriate to its subject,
0024
1 disadvantaged the separate professional strengths of the
2 professionals. It really has been with the development
3 of the scientific base of our subject that there has
4 been the necessary assertiveness to win the points in
5 paragraph 2.6.
6 Q. So in other words, the profession of paediatrics was
7 seen as being something of a softer option, if that is
8 not too crude, both intellectually and scientifically
9 until a relatively late stage?
10 A. No, I would not be able to agree with the way you put
11 it: might be and was regarded as a gentler subject, but
12 no less rigorous in its intellectual challenge. You may
13 read the works of Donald Winnicott and realise the
14 extraordinarily intellectual challenges that he
15 addressed in the 1940s and 1950s: no less a challenge,
16 but gentler in its approach at that time.
17 Q. But at what point was the fact of the intellectual
18 challenge that the profession demanded or required of
19 its participants generally recognised amongst other
20 medical disciplines and specialties?
21 A. It would be progressively in the 1950s, in the period
22 since the end of the Second World War.
23 Q. How would say, then, that the status of paediatricians
24 and of children's health services and professionals
25 compare to that of other branches of medicine now, at
0025
1 today's date?
2 A. I think there is yet a backdrop of that atmosphere
3 I have described over the first half of this century
4 which leaves us, without, I hope, diminishing one jot of
5 our compassionate care for children and their families,
6 to have to be rather more than less assertive to appear
7 politically as equals.
8 Q. If we push that back to the beginning of the period of
9 our terms of reference, 1984, would your answer be the
10 same or would you have to modify it in any way?
11 A. It would be the same. It was at the point on a rather
12 steep slope of the change in the professional standing,
13 both in nursing and in the medicine of children.
14 Q. If we push that answer down to the level of the
15 individual hospital, and in particular, a hospital,
16 a large hospital which has as a part of it a separate
17 Children's Hospital, how does the voice of those who are
18 managing and representing the Children's Hospital make
19 itself felt amongst the competing pressures of hospital
20 services as a whole?
21 A. If we were talking abstractly, and this was a children's
22 hospital within the greater building complex of an
23 all-specialty general hospital, then the normal
24 mechanism of representing views at the necessary
25 committees and the necessary presentation of documents
0026
1 and speaking to them and so forth would be equal among
2 equals. However, there was a tradition from which we
3 come that children's hospitals were in many places in
4 the world set up as castellated installations, separated
5 from the main, because it was recognised that the needs
6 of children were separate and required to be addressed
7 separately but that separatism has not historically
8 worked wholly to the best advantage of children.
9 Curiously, in Bristol itself, the very fact that the new
10 Children's Hospital is to be provided not on top of the
11 hill in grand isolation and in what was clean air, but
12 at the bottom of the hill, contiguous with the new
13 building, is I think a political statement that shows
14 that we wish to retain everything that is important and
15 separate about the health care of children, but we need
16 to be contiguous with the whole of medicine.
17 Q. Since you raised the example of Bristol and the
18 Children's Hospital, how does the new political
19 statement, as you have described it, compare with the
20 pre-existing situation where the Children's Hospital was
21 'up the hill' and therefore at least physically
22 separate from the remainder of the hospital?
23 A. It is still up the hill, and it does require an
24 additional effort to go down the hill to join the
25 necessary committee meetings and policy making groups
0027
1 and so forth to win an equal share of the discussion.
2 That requires an additional effort. That effort goes
3 on, but we hope that we will be able to represent the
4 case of the need of the health care of children that
5 much better when we are on the same side.
6 Q. Turning back to the question of the Royal College's
7 mission in this general area of the advance in the
8 interests of children, what do you see as the College's
9 mission in the next five years or so of its
10 development? Perhaps at this point it might be of
11 assistance if we turned up page 46 of your witness
12 statement, where the College's document, its Child
13 Health Strategy, is set out. That is of course just the
14 first page of it.
15 A. Might I just interrupt? On the front sheet is
16 a statement which, if I may turn to the Panel, we made
17 with serious intent, calling our strategy a "Children's
18 Health Service", since we believe that our
19 responsibility certainly includes setting and
20 maintaining the standards of paediatric practice. But
21 we see our responsibilities as being wider than that and
22 working with other agencies and pressing government that
23 we shall have a child-centred Health Service in the
24 country.
25 Q. So how does that differ, if at all, from the traditional
0028
1 mission of a Royal College?
2 A. It is not for me to find fault with other mission
3 statements, but we took great care, after long debate,
4 in naming our College not the Royal College of
5 Paediatricians but the Royal College of Paediatrics and
6 Child Health, so that our focus should be on the health
7 needs, curative for the child who is sick, paediatrics
8 and child health, the preventative and health promoting
9 aspects of our discipline, and that to achieve that end
10 were these matters of setting standards and maintaining
11 quality of clinical practice, but they being means to
12 the end, and the end is where we have our focus and that
13 is where we must be judged.
14 Q. That of the Child's Health Service. It is fair to say,
15 if one looks through the document, it recognises the
16 very broad aspects that are engaged in securing
17 children's health, because they encompass social and
18 educational issues as well as purely, if I might use
19 that term, medical issues?
20 A. Yes, I agree.
21 Q. If we turn briefly to the foreword of the document at
22 page 50, it is written by you. You talk there about the
23 document defining the strategy of the Royal College and
24 again, there is the reference to the United Nations
25 Convention on the Rights of the Child. The aim of the
0029
1 document and the College as you have just been
2 describing is perhaps very briefly summarised there.
3 It is apparent that the College is clear upon its
4 mission towards children, but of course it is also
5 setting standards for paediatricians which form its
6 basic membership.
7 Is there perhaps a tension between the aims of the
8 College to set out a blueprint and to aim to participate
9 in the development of a Health Service for children, and
10 its duties or its loyalties towards its membership of
11 paediatricians?
12 A. There must be tensions. The metaphor we use in the
13 College is, it is healthy tensions that keep the mast
14 upright and the sails in appropriate tension to sail the
15 ship. There have to be tensions, but they have to be
16 managed. We use the UN Convention as our anchor, so as
17 the debates unfold, the debate is always brought back in
18 the best interests of the child, how shall we resolve
19 these issues?
20 So there are issues about the configuration, the
21 shape of health services that we would wish to influence
22 to come, and how that will balance against the number of
23 consultant paediatricians that there are and the number
24 that we think there should be, and how we will manage
25 our work today and how we would wish to manage our work
0030
1 in five years time, in the best interests of the child.
2 If I can give an example there, which I think is
3 perhaps relevant to some of our discussion, there would
4 be modelling which would say in the best interests of
5 the child and family, they would want their health care
6 in their immediate neighbourhood. If we then look at
7 that from the professional point of view, to deliver the
8 best health care in the best interests of the child, if
9 this is an uncommon condition, the conclusion would be,
10 that cannot be delivered in every neighbourhood because
11 there has to be a certain quantum of work to maintain
12 the expertise of the practitioners. That leads one to
13 conclude that there has to be a configured tertiary
14 centre with sufficient throughput to justify that rare,
15 uncommon, perhaps highly technological work, which is
16 not in the family's backyard. And there is a tension.
17 But in the best interests of the child one would then
18 try and form a resolution to that and make that our
19 proposal.
20 Our conclusion in our consultations with families
21 is that if we professionally believe it is in the best
22 health outcome interests of the child to travel
23 a distance for the more highly experienced, highly
24 technological, rarer kind of care, then that is the wish
25 that we believe families would go with, even though it
0031
1 takes the care away from their home base.
2 Q. I would like to come back, if I may, to the issue of
3 tertiary services and the tension that may, on occasion,
4 be manifest between geographical location and the
5 development of expertise, but to return to the issue of
6 a possible conflict between developing children's
7 services and the interests of members. The crude point
8 that might be put against the College in its aspiration
9 to manage both of these things is the large dependence
10 which it will inevitably have for its funding upon
11 membership subscriptions and the support of its members,
12 both financially but also in more indirect fashions.
13 If we look, for instance, at page 151 of your
14 statement, this just by way of an example is the
15 College's last year's published accounts, and it is
16 obvious from there that the membership subscriptions
17 that year came to just under œ1 million, and represented
18 just under half of the College's total income.
19 It is also fair to say that you make the point in
20 your statement that in the coming year the dependence on
21 membership funding will go down to roughly one-third,
22 but what do you say about managing possible tensions
23 between these two loyalties in the context of quite
24 a major dependence upon members for funding and other
25 forms of support?
0032
1 A. I find your question original, in that I have never
2 encountered a tension in the way that you have put it.
3 It may be part of the newness of our College, but there
4 has not been, at any of our debates, at our very
5 powerful vocal Council meetings, a challenge that our
6 members will not buy into this. We are still
7 a vocationally driven specialty, and the importance of
8 our accounts is that we look to our Finance Committee to
9 keep us solvent. But the issue of, "Will we be able to
10 carry our members with us on such a recommendation?" for
11 example, if the recommendation was that to deliver the
12 Health Service in the best interests of children,
13 consultants should have to start living in hospital, we
14 would have quite a debate on our hands.
15 But I would not have considered, until you raised
16 the question, that anyone would have started to threaten
17 withdrawing their subscription. The atmosphere is not
18 set in this way.
19 Q. So, so far, does it follow from your answer that you
20 have managed to manage any tensions, or conflicts that
21 may exist between the interests of paediatricians and
22 the interests of the child without any real difficulty?
23 A. I think that is the key, and I think it is because --
24 I like to think it is, in my earlier remarks, there is
25 still a selective sorting of who goes into the health
0033
1 care of children, and they are people committed to the
2 health care of children. The tension is, "Which is the
3 better moral?" and then we will have a lively debate and
4 try to take our anchorage from the best interests of the
5 child.
6 Q. Does the College's endorsement or advocacy of a proposal
7 for the position of a national Children's Commissioner
8 have any part to play in this particular debate?
9 A. It is an aspiration of the College. It has been
10 discussed in our Council, which is a representative
11 Council, and is strongly supported by our Council and it
12 is something to which we are committed, and will
13 continue to work. And if I have to give some brief
14 justifications for that view, which I think is a view
15 that is shared by our colleagues in the Royal College of
16 Nursing, that it is one thing for us in the best
17 interests of the child to work out a policy, to have
18 a policy statement, to place it before Her Majesty's
19 government; it is another matter to ensure that it is
20 implemented, and it is our view that the office of
21 a Children's Commissioner, a children's rights
22 commissioner, an Ombudsman for children, looking
23 sideways at government, in the best interests of the
24 child without any question, for that would be the
25 purpose of the office, would be our best safeguard that
0034
1 recommendations, and in our work recommendations for the
2 health care of children, would have a body standing
3 which would say, "In the best interests of children,
4 that should be implemented; it has not been implemented,
5 Her Majesty's government must be answerable, why has it
6 not been implemented?"
7 Q. Thank you. You mention there the Royal College of
8 Nursing, and perhaps that is a point on which we could
9 pass to the general issue of the shortage of nurses
10 trained in paediatrics throughout the NHS during the
11 period again of our terms of reference, 1984 to 1995.
12 We have heard already a great deal of evidence of
13 the general shortage of such nurses, and of course the
14 British Paediatric Association, as it then was, did
15 a great deal to point that up through a number of its
16 reports and working party documents throughout our
17 period.
18 Can I ask you, however, that assuming that general
19 background as read, what impact do you think the absence
20 of a trained children's nurse upon a ward would make to
21 the care of that child?
22 A. I believe there would be, and is, a great impact flowing
23 from the presence or the absence of a children's nurse
24 trained presence on the ward, to prove that case is very
25 difficult. I would have initially to begin by restating
0035
1 the differences between children and adults, more
2 strikingly so younger children, more strikingly so the
3 new-born, to rehearse the difference in their
4 physiology, in their fluids, in their drug requirements,
5 in their physical signs, in the subtleties which would
6 lead a skilled, that is a trained nurse, in children's
7 health care to say "That child is not well", "That child
8 is blanching", "This child will anticipate pain from
9 this procedure", to be the guardian of the young child,
10 the baby.
11 I think those are substantial differences.
12 To prove it made a difference would be an
13 extraordinary long-term study which would require,
14 I suppose, the randomisation of children or children's
15 wards without such special care nursing, and it would be
16 a long and very expensive experiment and no doubt will
17 take some years to have outcomes, but I think it would
18 fall at the first ethical fence that I think sensible
19 people would judge, and you cannot do that experiment
20 because it is manifestly the case that children should
21 be looked after by children-trained staff.
22 Q. Does it follow from what you have said that if we were
23 to start searching through scientific journals in search
24 of such evidence we would not find it, but that the
25 evidence comes both from the basic theory of children's
0036
1 nursing plus possibly anecdotal evidence of the
2 importance of the interventions that particular nurses
3 have made on particular occasions?
4 A. Yes. I think that is the case. But I would not wish to
5 decry anecdotal evidence. I think qualitative
6 observation research has served mankind very well, and
7 should not be discarded because it is not a mega
8 randomised trial.
9 Q. So the term "qualitative evidence" rather than
10 "anecdotal evidence" may be preferable for that
11 reason?
12 A. It may, but I would not always give ground because
13 I would wish to win back the respectability of anecdotal
14 evidence. Sigmund Freud did not do too badly on
15 anecdotal evidence.
16 Q. On the question of availability of paediatric nurses,
17 are you able to help us from the point of view of your
18 own recollection of the position of the Children's
19 Hospital in Bristol during the period again 1984 to
20 1995?
21 A. I would make some observations. I cannot be tied to the
22 quantitative detail.
23 Q. I appreciate that I am asking you this question without
24 the benefit of any documents, purely on the basis of
25 your own recollection at this date.
0037
1 A. But it was, and indeed, is the case, that when
2 a hospital like our Children's Hospital talks in terms
3 of bed closure, insufficient beds, difficult in opening
4 beds at night and so forth, it is not of course the
5 structure of a bed; it is a sufficiency of trained
6 nurses to safely have a sick child in a bed. That
7 certainly was an issue, has been an issue ever since
8 I have been in Bristol; it has improved somewhat in the
9 last year or two, with some very imaginative management
10 of the budget and of the personnel at the Children's
11 Hospital, and I think we are well set to do this much
12 better with the new hospital, which would bring certain
13 additional advantages.
14 So there certainly were limitations, as my memory
15 goes, for the late 1980s and early 1990s.
16 Q. Can you help us by placing that answer in its national
17 context at the time, if we had been asking this question
18 of other children's hospitals, do you, in your own
19 experience, think that the answer would have been
20 substantially different?
21 A. No. I think this would be the national picture. If
22 I may have a minute just to enlarge on this to the
23 Panel, it is engraved on my mind, and other parts of my
24 anatomy, that in the early development of the intensive
25 care of babies, we made recommendations that to look
0038
1 after a high dependency baby in a Neonatal Intensive
2 Care Unit would require an establishment of 5 full-time
3 equivalent of nurses. We actually said 8, and people
4 threw up their hands, "This is ridiculous."
5 When we came down to a figure nearer to five,
6 there were counter arguments, but it is a very small
7 patient. Until we were able to make the needs -- it is
8 nothing to do with size, it is to do with the intensity
9 of care of a sick baby which requires the undivided
10 attentions of a nurse for a shift and even our dedicated
11 nurses are not able to work 24 hour shifts and they do
12 require some respite time and some study time. You
13 factor that up and you have an absolute of five
14 full-time equivalents.
15 So we have to break through barriers of small
16 people needing fewer staff to the understanding that
17 these are whole-time people, these children and babies,
18 who require whole-time staff and the sicker they are,
19 the more complex the health care techniques, the more
20 dedicated completely preoccupied attention from the
21 nursing staff attending, therefore the more are needed
22 in the whole staff of the hospital and that produces
23 tremendous difficulties, both in having the budget to
24 employ the staff, but downstream or upstream to have
25 enough nurses coming through that training.
0039
1 I am sorry it was a slightly long answer.
2 Q. Can I just take that a little bit further, because one
3 of the issues that then arose out of the recognition of
4 the special needs of children was the beginning of the
5 questioning of the adequacy of mixed adult and
6 paediatric wards in specialist services.
7 First, I think it is probably right to state for
8 the record that you yourself were not involved or had no
9 reason to be involved in the intensive cardiac ward in
10 the BRI?
11 A. That is right. I was at the Children's Hospital and the
12 Institute of Child Health on top of the hill.
13 Q. But if I can ask you more broadly to look back again to
14 1984 and to ask yourself and to assist the Panel on how
15 important it would have seemed to health care
16 professionals at the time to ensure that children were
17 not, when we are talking about such specialised
18 services, nursed on mixed adult and paediatric wards at
19 that time?
20 A. At that time, if one were looking at or were preparing
21 a policy document, I have no doubt that the conclusion
22 would have been very firmly, these should be separate
23 entities. That would apply if one was talking about the
24 mix from adolescents and adult, let alone younger
25 children and babies, let alone if they were profoundly
0040
1 ill.
2 In the 10 to 15 years since the time that you are
3 addressing, we have progressed somewhat, but it has only
4 been in the last two or three years that under the
5 heading of paediatric intensive care services, as you
6 know, the government has come down on the side of not
7 only having a policy, but actually implementing
8 a policy, so that in all parts of the land we are still
9 at the implementation phase, there should be a separate
10 fully equipped, fully staffed Paediatric Intensive Care
11 Unit. That has still not been totally achieved for the
12 nation in May 1999.
13 Q. But if the policy document would have looked the same at
14 the beginning of the decade as it would now, what were
15 the obstacles to realising that policy, again in the
16 earlier part of our period?
17 A. It would be multi-factorial. There would be a directive
18 from government down to implement such a policy. There
19 would be the --
20 Q. I am sorry, if you I stop you, do you mean the absence
21 of such a directive?
22 A. Yes. It would require a directive; it would require
23 a directive as powerful as the current directive, which
24 is, as I understand it, an absolute one, that there
25 would be no local choice over the matter, and it is
0041
1 only, as I say, in the last year, and currently, there
2 is no choice over the matter of having separate
3 paediatric intensive care units, so it would have
4 required a clear directive, which I believe there was
5 not; it would have required a local commitment which was
6 a matter then of discretion, and then, if it is a matter
7 of discretion, it is looking at the relative competition
8 of other priorities, financial issues, the tremendous
9 delay that is essential in reorganising a service, let
10 alone rebuilding physically a service, quite apart from
11 the staffing structures and so forth.
12 So even from the moment of recognition, even from
13 the moment of a government directive, there is
14 necessarily a lag-time.
15 Q. Can you help us as to what has changed to bring
16 something that was recognised as a matter of theory or
17 a matter of policy writing in 1984, right up to the top
18 of what one might call the hospital agenda at the end of
19 our period, so that it becomes not a matter of
20 discretion but something that requires to be
21 implemented?
22 A. I hope I will not be indiscreet. One element has been
23 a change in government to move away from the competition
24 in health care delivery to sensible planning and
25 collaboration. That has been a major factor in
0042
1 answering your question.
2 Under the spirit and heading of "collaboration"
3 has been this realisation that for some subjects we have
4 to have networks of specialist locations where things
5 can be done, specially because the number and the
6 intensity require a specialist centre going back to what
7 I said earlier, albeit a distance from the family home.
8 Then, most tragically, but so much of life and
9 history is like this, it required a high profile, huge
10 tragedy to make it inescapable in government terms. So
11 there was the poor child in the north of England who was
12 moved from pillar to post, as you know, and the death of
13 that child raised the political energy that this was at
14 flashpoint; it was no longer conscionable.
15 That, I suppose, is the nature of our species,
16 that we require these tragedies to make things happen.
17 Q. If you were being asked to describe the mind-set of,
18 say, a hospital manager in 1984 -- I appreciate of
19 course that you were not such -- but you are looking at
20 such a person, and in 1984 he is confronting the
21 problem -- because it would be recognised even then as
22 such -- of a mixed adult and paediatric intensive care
23 ward, how do you suppose he would view the priority of
24 the need to make changes in that service, when set
25 against all the other priorities and demands that might
0043
1 be set against his hospital's resources at that time?
2 A. He or she would have to face tough decisions. There
3 would be repeating priorities, depending on who was
4 making the case locally, which documents and which
5 authority were being placed on his or her disk. But no
6 doubt there would be entirely practical elements of, "If
7 we separate them, where will they go?" "If it will
8 require additional budget, where will I get the budget
9 from ?" "It requires this development, but by making
10 this my priority, I will have to put that on
11 a backburner", facing up to the political fallout of
12 that decision.
13 Q. What I detected in some of your answers is a general
14 concern about the danger of judging this issue with the
15 benefit of hindsight. Is that a fair observation?
16 A. It is a fair observation, because on this point we are
17 just discussing, even now, in 1999, there are in the
18 country children being cared for on adult intensive care
19 units. The matter is not totally yet sorted. It will
20 be, I hope, within the 12 months.
21 With hindsight, it is such a difficult task you
22 have. In my reflections before we came in to you, I had
23 at the bottom of my paper, "chimney sweeps". Well, it
24 was obvious perhaps to Charles Dickens that that was
25 a bad idea, but it was not obvious to our Victorian
0044
1 ancestors. It was not obvious to me in the middle 1960s
2 that babies should be delivered in the same physical
3 configuration as the Neonatal Intensive Care Unit.
4 I spent many of my formative years running at another
5 hospital across a car park and through a tennis court
6 with a sick baby in my arms to go from the delivery ward
7 to the Neonatal Intensive Care Unit. It was becoming
8 apparent that this was a bad arrangement. It took
9 several years to have the budget and the will to
10 rearrange that so they were cheek-by-jowl. It is very
11 difficult to get it right in the historical context.
12 Q. Could I ask you to look, please, briefly at the
13 Department of Health standards in 1991 in the Welfare of
14 Children? That is at HOME 2. The document starts at
15 page 1, but if I could take you directly to page 13,
16 please. This is, as I say, from the Department of
17 Health standards in 1991 and it recognises there the
18 desirability of caring for all children within
19 a children's department or children's hospital, and
20 grouping of children together obviously facilitates
21 a number of aims.
22 But the first mention there is that it enables
23 a children's physician or surgeon, i.e. a paediatric
24 specialist, to participate in the general management of
25 and professional oversight of a department, even though
0045
1 responsibility for the individual child's medical care
2 may rest with consultants in specialties other than
3 paediatrics.
4 Can I ask what would be the understanding of the
5 importance of a paediatric oversight or input into even
6 mixed adult and paediatric wards within a hospital
7 during the period with which we are concerned?
8 A. I would interpret the notion in bullet point 1 to mean
9 that the conductor of the orchestra has to be
10 a paediatrician in order to integrate the specialist
11 care of, let us say, an ear, nose and throat surgeon,
12 together with the necessary ear, nose and throat
13 nursing, but orchestrated into that the health care
14 needs of that particular child in their stage of growth
15 and development, their particular physiological needs
16 which might be very different from an adult approach to
17 fluids, to electrolytes, to drugs, taking into account
18 their position in the family, the health care of the
19 parents, other siblings, educational needs, the social
20 setting, and so on. It is a very big orchestra to be
21 held together, but sometimes one has to let the bassoons
22 play so low.
23 Q. How does the general idea of orchestrating a child's
24 care through the media of a paediatrician play when the
25 child is being cared for on a mixed adult and paediatric
0046
1 ward in a separate part of the hospital that does not
2 form part of the Children's Hospital?
3 A. I think your question is very powerful and well put. It
4 is extremely difficult at another hospital which is not
5 on my normal beaten track where I am an occasional
6 visitor trying to orchestrate something at a distance.
7 It was not designed to work well. That is, of course,
8 the whole argument for bringing things together within
9 the polarity of a children's hospital.
10 Q. If we perhaps move on to the general issue of how the
11 changes in the organisation of the NHS in around 1991
12 affected the delivery of children's services, we might
13 briefly have a look, please, at the Audit Commission's
14 report of 1993, "Children First", at HOME 1/132.
15 I think we will find that is just the title page, to
16 give us the reference.
17 Then, if we move on, please, to page 195, the
18 Commission there talked about strategic commissioning
19 for children's services, and it set out the need for
20 a clear and consistent strategy for commissioning
21 services for children, as being important. The DHAs at
22 that time were the main commissioning authorities, and
23 they needed to set a framework in which the providers
24 operated.
25 If we scroll down a little bit, it talked about
0047
1 the problems of lack of commissioning strategies, poor
2 specification of services in contracts, inadequate links
3 between commissioning authorities and providers, and
4 lack of attention to the need for change.
5 In particular, if we look at paragraph 144, it
6 talks about the fact that it was new, this role, for
7 DHAs, and that very few had firm plans for developing
8 a strategy. The assessment of needs for children was
9 very much in its infancy, and, in the last sentence:
10 "Some DHAs do not even classify children's
11 services as a separate entity, but group them with adult
12 services, particularly in contracts for surgery."
13 Do you have any experience or did you encounter
14 the issue of how children's services were managed as
15 a contracting issue after the introduction of the NHS
16 reforms in 1991?
17 A. Not personally.
18 Q. Are you able to comment, therefore, on whether or not
19 the DHAs, the Commissioners of Children's Services,
20 generally rose to the challenge of commissioning or
21 providing a strategic cause for children's services?
22 A. On that I may comment. I think I am right that only in
23 one DHA in the land was there a designated Children's
24 Commissioner. I think that has been in Oxford. In very
25 few of the DHAs -- I put it in the past tense since
0048
1 I believe we are moving into the Primary Care
2 Commission, which may produce even more difficulties
3 until we get it right, that it was a minority of DHAs
4 that had anyone with a designated portfolio, let alone
5 a totally designated children's health commissioner.
6 I think that what is said in paragraph 144 was not
7 enacted, was not implemented, and to a worrying degree,
8 still applies.
9 Q. So that if the Audit Commission noted that children's
10 services were often grouped with adult services,
11 particularly in contracts for surgery, that is something
12 which you would agree with?
13 A. I would agree with.
14 Q. Who, in general, would you have regarded as being
15 responsible for identifying the need for children's
16 services?
17 A. We cannot be innocent in this as a profession. If
18 I were to take the view that it will be the District
19 Health Authority that must place the contract for the
20 services, I have my job to represent the need for that
21 contracting to the DHA, and there the thing goes in
22 a circle. The vigour and efficiency with which we make
23 our case will, to some extent, affect the strategy of
24 the DHA.
25 Q. What about the Regional Health Authority and the
0049
1 national role of, say, the NHS Management Executive or
2 the Department of Health? What part do they play in
3 this jigsaw?
4 A. I think you just made a case for a Royal College of
5 Paediatrics and Child Health.
6 Q. If we look at that role, then, we can look at page 46 of
7 your statement once more, where we had the beginning of
8 the College's strategy for the next five years. In your
9 statement in general, you talk about the many functions
10 of the Royal College. One of them has obviously been to
11 provide advice and assistance to its members.
12 Could I just take you briefly, as a commentary on
13 that particular part, to page 56, where you talk about,
14 or the College talks about the general need for
15 a co-ordinated child-centred Health Service which
16 serves the needs of the child and the family, and there
17 the agenda for action is set out. Perhaps we could just
18 scroll briefly through that.
19 Does that strategy there arise out of what we have
20 just been discussing, the need for co-ordination in the
21 area of commissioning children's health services?
22 A. Yes, very much so. I would like just to enlarge on one
23 point within it, which is, if you like, it begins with
24 a philosophical position, or a slogan, that an admission
25 of a child to hospital is a failure and that we look
0050
1 towards our strategy and the commissioning to be
2 a unified service, paediatrics, child health from the
3 hospital intensive care bed to the consultation with the
4 family doctor and that that seamless, co-ordinated
5 delivery and planning of health care for children is
6 part of the strategy embedded in this page.
7 Q. Professor Baum, I would like, if I may, to turn to the
8 area of the maintenance of standards. However, it may
9 be that it would be appropriate at this moment to take
10 a short break, for perhaps 10 minutes, before resuming,
11 if that is acceptable to you, Chair?
12 THE CHAIRMAN: Yes, shall we do that, take 10 minutes and
13 therefore reconvene at -- I am now nervous because
14 Mr Langstaff reminded us no clock shows the same time.
15 May I suggest a quarter to? Would that be more or less
16 accurate?
17 MISS GREY: Thank you.
18 (11.30 am)
19 (A short break)
20 (11.47 am)
21 MISS GREY: Sir, I am extremely sorry we should have been
22 late. I blame on this occasion Mr Langstaff's watch
23 which is still clearly badly co-ordinated. I apologise
24 both to you and Professor Baum.
25 THE CHAIRMAN: Just let me say, although we can smile, it is
0051
1 important that we do get it right, so perhaps we will
2 talk about synchronising our timepieces in due course.
3 MISS GREY: If I smiled, it was not through any want of
4 contrition.
5 Professor Baum, if I can turn to the question of
6 maintenance of standards by the College, generally, if
7 one looks at your statement, it underlines the changes
8 in this area from the point of view of the College,
9 which underlie or derive from the move from being
10 a professional association, the British Paediatric
11 Association, to being a full Royal College.
12 I am looking at page 23 of your statement; where
13 at the end you emphasise the difference in the
14 standard-setting mechanisms which are now available to
15 the College in contrast with the relative paucity of
16 mechanisms that would have been available to the British
17 Paediatric Association at the beginning of the period of
18 our terms of reference.
19 Could I ask, then, please, if we look now at
20 page 10 of your statement and paragraph 1.21, where
21 there you talk about the increasing greater regulatory
22 and disciplinary powers and responsibilities available
23 to the College, and you distinguish there between the
24 GMC and the College by saying:
25 "To reduce the distinction to its simplest terms,
0052
1 the College sets professional standards: the GMC
2 enforces them."
3 You add that "The BMA as the doctors' trade union
4 has an active interest in both, but is ultimately
5 responsible for neither."
6 May I ask, how does the College see the balance in
7 responsibilities between firstly the College; secondly
8 the GMC; and thirdly that of a local employer or
9 Hospital Trust, since that might perhaps be said to be
10 the element in the picture that is missing from that
11 particular paragraph of your statement?
12 A. I would find it easiest to construct my answer if
13 I could see the flow diagram relating to good standing.
14 Can that come up on the screen?
15 Q. If you can help me as to where it can be found, yes.
16 A. It was one of the annexes.
17 MRS HOWARD: Miss Grey, if I can help you, it is WIT 36/60.
18 MISS GREY: Thank you very much. Can we have page 60 up,
19 please?
20 A. That is it, thank you. Forgive me asking, it just gives
21 me a structure which with I can answer your important
22 question. The important part of your question was about
23 the Trust's role in the management and quality of
24 practice, but to run up to that, this diagram
25 illustrates our opportunities for controlling the
0053
1 quality of training and then of achieved standards by
2 those who are deemed to have reached consultant
3 standing.
4 So from the entry point at the top, we have the
5 Senior House Officers who are themselves of course
6 graduates, they are bright, dedicated, hard-working
7 people, but they are in good standing to take the first
8 exam, the MRCPH, they require to have references from
9 their consultants to say "These are suitable people to
10 go on in training".
11 They then face the ordeal of the professional
12 exams, and I will not go into that in detail. If they
13 pass through that exam, they are then deemed to be
14 a member in good standing. They are so far in good
15 standing having had their consultant's references and
16 passed the professional exam.
17 Q. Can I stop you there by asking what percentage would
18 generally pass and what percentage would fail?
19 A. We are still in the process of inheriting the total
20 control of the exam from the Royal College of Physicians
21 and it is in the order of two-thirds passing.
22 Q. Thank you.
23 A. However, we look to a day when it will be 95 per cent
24 passing, not through a drop in standards, but through
25 appropriate training, so exit from a university, one
0054
1 does not expect half to fail, one expects the majority,
2 90 per cent, to have reached the required training and
3 standards.
4 They then face a competition to enter into higher
5 training. This requires further satisfying of
6 a committee that they have the appropriate attributes,
7 in addition to what they already have, to go into higher
8 training.
9 They then spend five years in higher training,
10 which are no longer meandering, dipping in and out of
11 experience, but a highly stratified episode of training
12 in which there is appraisal at every step and an annual
13 appraisal with the Regional Adviser of the College and
14 the Post-graduate Dean. So it is quite closely
15 regulated to make sure they are progressing
16 satisfactorily. At the end of that time, there is no
17 exam but there is a summation of their progress and look
18 at their portfolio, and one does not expect people to
19 fail at that time, but may expect to find along the way
20 somebody who needs a little more of this, that or the
21 other or somehow their manner or style needs correction,
22 and we hope the antennae will be sensitive enough to
23 adjust that.
24 They then will be judged to have completed their
25 training and we then, as the standard setter, will
0055
1 recommend to the specialist training authority, which in
2 that very brief note you showed me perhaps naughtily
3 I assumed the GMC is a proxy for that as well, but
4 specialist training authority independent of the GMC,
5 answering to European legislation, will accept our
6 recommendation because they have scrutinised our whole
7 process of training regulation. If we will provide the
8 necessary documents -- and it is quite a dossier of
9 documents -- to support and recommend somebody receives
10 their certificate of specialist training, then they are
11 so given it. Then they recommend to the GMC that the
12 name goes on the specialist register.
13 We then invite them to take the College oath and
14 all this is contemporaneous history. We have only just
15 entered into this phase in our development, but the
16 first Fellows have taken the College oath and that is
17 a very serious issue: that they are signing up to X
18 number of paragraphs which commit them to certain
19 components of their professional life.
20 They will then go on as a Fellow of The College in
21 good standing, so far, and then we enter into very much
22 contemporaneous history, the proposed ideas for
23 revalidation, which, even were it to be the case,
24 I think, that the General Medical Council did not impose
25 cyclical revalidation, we are sufficiently committed to
0056
1 it that we believe we will proceed and are on the way to
2 proceeding down this path, which I believe, knowing the
3 sad origins of these discussions, and I must remember to
4 tell the families concerned that, as paediatricians, we
5 naturally feel for them deeply; it is our professional
6 business to be alongside them in such difficulties and
7 tragedies. But nevertheless, there is a positive
8 outcome in that I think it has brought to focus this
9 particular development of, there was not in place
10 a process for periodically reviewing the standards of
11 practice of established consultants. I think that is
12 a very important world-leading development which our
13 College is committed to deliver, even if we are not
14 required to. Our image of it at the moment is that
15 perhaps five-yearly we will ask each of us to take stock
16 what has been the audit, the quality of our clinical
17 care over the last five years, what is our plan for the
18 next five years and that is what is captured in these
19 letters, CME/CPD.
20 Q. If we look further at the gap you have identified, the
21 absence of the periodic review of the established
22 practitioner, what would have been the mechanism for
23 dealing with the situation in which a number of
24 individuals, whether they were local colleagues of
25 a paediatrician or whether they were people whom he or
0057
1 she had encountered on the professional circuit or
2 something, and from one of the pieces of conversation or
3 so, began to have concerns about the quality of the
4 practice of that individual, how would that have been
5 addressed during that period?
6 A. This is a most important key question, bearing in mind
7 I still have not addressed your question about the
8 managerial Trust input, which I will come back to.
9 It was not all bad. Although there was no formal
10 mechanism as set out in this flow diagram, what was in
11 its place was the tradition -- tradition is not always
12 good, but I reckon this was a good tradition -- of
13 working in firms in that these are the consultants,
14 these are the training staff, these are our beds, these
15 are the nurses who are with us, and a certain 'tribal'
16 grouping, if you like, of people who hang together and
17 did this kind of work.
18 Within that format, there was, and I reflect back
19 very well upon this in my early career, many checks and
20 balances within that system of finding things which were
21 going astray and bringing them back, or taking remedial
22 action, not in a formal sense but in the group sense of
23 "this group hangs together by the strength of all its
24 links".
25 That has been eroded and lost over the last
0058
1 20 years because of more efficient use of hospitals, so
2 there is no longer a ward where Professor Baum goes to
3 see his patients, I will have one on ward 36, two on
4 ward 31, five on ward 37, because that is more
5 efficient. Of course with the civilising reduction in
6 the working hours of the junior staff, there is no
7 longer my SHO, who has been on all week, it will be
8 a series of people working shifts.
9 Putting all that together, we have lost
10 a coherence that did still apply in the late 1980s/early
11 1990s which was itself a check and balance on the system
12 and within that framework, in my belief, there would be
13 a resonance of "something is going wrong" which would
14 have either been addressed or would have been made known
15 to the managerial committees. That was the check and
16 balance.
17 Q. Why do you say that it would have been addressed in that
18 situation, because the danger of the scenario that you
19 paint is that it was a hierarchical model with
20 a particular consultant at its head, and that such
21 a system might be good at dealing with problems in
22 performance or competence of a more junior member of the
23 team, but might have difficulties in coping with
24 a person who had flaws who was at the apex of that
25 structure?
0059
1 A. A most important and well put question. I cannot sweep
2 it aside or gainsay it in any absolute way, but my
3 belief is that by virtue of the firm being
4 multidisciplinary, most particularly looking to our
5 nursing colleagues who, in my experience, have been the
6 fighting champions for the child, that the system did
7 have sufficient checks and balances that a rogue
8 consultant would not have been able to conduct her or
9 his work outside bounds of acceptability. I think there
10 were sufficient checks within the overall system that it
11 was not only rooting out difficulties in juniors.
12 Q. So the route would be to discuss, to try and deal with
13 difficulties within the firm, and if that failed, you
14 suggested, I think, a minute ago, that a problem might
15 be taken outside it to hospital management; is that
16 correct?
17 A. That is right, yes.
18 Q. Would it be a managerial route that was sought to
19 resolve a problem like this, or would it be something
20 that remained amongst clinicians for rather longer by
21 appealing, as it were, up the clinician structure rather
22 than the management structure?
23 A. Yes. At that time, probably, you are right that it
24 would have been first addressed among other senior
25 clinicians, and it is my belief that they would not have
0060
1 ducked the responsibility if something was going amiss
2 and it needs to be addressed.
3 Q. So at what point, if at all, does it become a hospital
4 management responsibility?
5 A. I think I am ducking this question because I do not see
6 the lines of demarcation clearly enough as they were in
7 1989/1993. If I can guess at it, depending on the
8 nature of the problem, it would have either gone to the
9 senior medical staff committee which, of course, would
10 be a Joint Committee with management, but other species
11 of the problem might have looked to its Royal College
12 with the "three wise person" mechanism and taking it up
13 to that route, or there might have been a sufficiently
14 clear view that the matter would have been taken
15 straight to the GMC.
16 Q. If it is difficult to answer the question, is that
17 because we are talking at a level which is too abstract
18 and it depends on the nature of the problem, or is it
19 because there were changes and flux in the balance of
20 responsibilities of managers and clinicians during the
21 period we are talking of?
22 A. I think it is because Professor Baum was never involved
23 with those structures, and was never an active
24 participant in hospital management, senior medical staff
25 committees, at that time, so I actually do not have
0061
1 a clear memory or even at the time, I do not think I had
2 a clear image of how it might be handled.
3 Q. Could I ask you to go back, then, to the question where
4 we started, which was to ask you to outline how you
5 would see the balance of responsibilities between the
6 College and, I think, realistically, if we are pushing
7 it into the back -- because in a sense one is talking
8 about the Royal College of Physicians rather than the
9 Royal College of Paediatrics and Child Health, but the
10 Royal College, the GMC and the local Hospital Trust or
11 management.
12 A. One reason why we are so enthusiastic about what is the
13 outcome of this Inquiry -- one of the outcomes -- is
14 that under these words "CPD", continuing professional
15 development, the model we are working towards is that if
16 I am now preparing for my next year's quinquennial
17 review, where I will be putting together a summary, an
18 audit of my clinical practice over the last five years,
19 I would be doing that in all likelihood with hospital
20 management staff to agree how many clinics I have done,
21 what number of patients had not attended, what I had
22 done about non-attending patients, and so forth, and
23 most certainly, setting out my five years work to come.
24 That can only have validity if the hospital, my
25 employer, is willing to employ me in those terms. So if
0062
1 I were narrowing my work that I am now only going to see
2 14 year-olds with diabetes and no other patients, they
3 may say that is not a sufficient contribution to the
4 work plan that will give you a contract, with that kind
5 of job description. I think it is in that future
6 planning of a quinquennial piece of work, where an
7 individual consultant, the Royal College, the GMC,
8 Trust, employer, University, would come together to say,
9 "Yes, that is something we will all sign up to as
10 a very sensible portrayal of how you spend your next
11 five years".
12 Q. What you are describing there is a system which is
13 proactive in developing professional standards so as to
14 avoid, one would hope, ever having to confront the
15 problem of the failing practitioner. If the College
16 succeeds that will not arise, but if one is talking
17 about a situation where somebody does appear on
18 anecdotal evidence to be presenting a problem to his or
19 her colleagues, and yet the five-year audit of the
20 College is still two or three years down the future,
21 what does the College do in that situation? Or what do
22 the other players do?
23 A. As you will see in our document, there is mention made
24 of our Professional Standards Group, and the notion
25 here -- and it is still on the brink of being a fact --
0063
1 that we are encouraging all our Fellows to think in
2 terms of, "if any part of your work is providing
3 difficulties, or any of your colleagues to your opinion
4 are getting into difficulties, come and talk to us about
5 it, and let us consider things like retreading your
6 skills, or reflecting that if you are in a highly
7 technical part of your work and you are finding your
8 dexterity is not what it was, then let us consider how
9 best to use all your life experience". This might be
10 the time to say, "I will now have a brief Sabbatical and
11 move out of the hands-on technical care and do some
12 other related branch of my subject, which I can do but
13 without my dextral skills". I think it does depend on
14 winning the Trust of our Fellows, that we would like to
15 help everyone adjust and help their careers develop, but
16 occasionally statistically it must happen that somebody
17 will be failing in their competence and will not take
18 the path that we are offering them, and then we have
19 entered a new culture where this will not be tolerated
20 by colleagues because we will hold our College Fellows
21 responsible, if knowingly they were not alerting us to
22 a failing in standards.
23 Q. So the corollary of that is what action would follow?
24 A. And then we would ask a colleague to meet with our
25 Professional Standards Group and make our own
0064
1 "enquiries" is perhaps too powerful a word, to have
2 a discussion, and if as a result of that we are agreeing
3 there were remedial pathways to take, we would recommend
4 them and hope we would put in place the checks and
5 balances to make sure they would follow through, if it
6 was outwith that kind of corrective programme, then we
7 would openly say "This is a matter we must refer to the
8 General Medical Council".
9 Q. That is the stance the College has arrived at now. Is
10 that an understanding of how the problem should have
11 been approached that would hold true for the period 1984
12 to 1995, or has the answer changed more recently?
13 A. I think the detail has changed beyond recognition. If
14 I can back to my previous model of the firm, I think the
15 firm would have contained, would have encouraged,
16 remedial action, if this was not sufficient, would have
17 taken it to the medical staff committee and so forth.
18 It probably would have meant, at that time, that
19 somebody's performance or behaviour was three standard
20 deviations from the norm before somebody said "This is
21 just intolerable", and it would be a more exaggerated
22 point that would go to the GMC, whereas I hope today we
23 would be at a much more blurred margin so there was much
24 more corrective work rather than disciplinary work.
25 Q. But ultimately, does it follow from that answer that if
0065
1 a college -- I am talking now of the medical colleges --
2 discovered that there was reason to be concerned about
3 the performance of a particular practitioner, and that
4 there seemed to be no signs that the firm or the local
5 structures were dealing with that situation, that
6 ultimately it would have an obligation to refer to the
7 GMC if no other corrective mechanism seemed to be in
8 play?
9 A. Yes, that is right.
10 Q. Just a point of detail about the membership of the Royal
11 College of Paediatrics. We have been speaking this
12 morning about paediatricians. What about the position
13 of paediatric cardiologists? Where would they be likely
14 to find their home these days?
15 A. Ours is a medical Royal College, and 99 per cent of our
16 Members and Fellows are medically qualified. We have
17 some 15 specialty groups, supra or subspecialty groups,
18 to cover the various 'ologies -- nephrology,
19 gastroenterology, neurology and so forth. It happens
20 that the paediatric cardiologists, in the evolution of
21 our College, maintained largely their identity with the
22 College of Physicians, the Specialist Advisory Committee
23 on Cardiology, as the group to which it looked for
24 recommendations for training and subsequently for CCST,
25 and subsequently for their CME regulation.
0066
1 That is how it fell out. I am not sure at the
2 moment how it is going to work out. In preparation for
3 today, I tried to find some figures to illuminate this.
4 The best I can offer is that we do have a paediatric
5 cardiac group of our College and I think that there are
6 something like 44 members of that group, of which 6 are
7 medical scientists, not clinicians -- I think this is
8 about right -- and of that 38 who are clinician doctors,
9 paediatric cardiologists, four are currently looking for
10 their continuing medical education with our College,
11 which means the remainder are College of Physicians or
12 elsewhere.
13 I know Professor Alberti sent out a questionnaire
14 to find out where they are looking to for the CME, but
15 it is a historical event which is not entirely random.
16 Most paediatric cardiologists were, in the 1980s and
17 early 1990s, coming from training in cardiology, and
18 then specialising in paediatric cardiology, so they were
19 coming from physicians hanging out with cardiologists to
20 become paediatric cardiologists.
21 This is on the change, but across Europe, this is
22 not just this country, this subspecialty in paediatrics
23 which is separate from the confederation of specialties
24 is paediatric cardiology.
25 Q. With the development of continuing professional
0067
1 development and accreditation schemes, it is likely that
2 these particular subspecialties will have to choose one
3 home or the other, rather more definitively than they
4 have had to do so far; is that right?
5 A. I think so, unless, which I think would be a better
6 outcome, we have the administrative organisational
7 powers to have joint committees of supervision, which
8 would be a better outcome, but is administratively quite
9 a difficult thing to deliver.
10 Q. Could I ask for your assistance on the matter of
11 referrals from paediatricians to paediatric
12 cardiologists? If we look at the evidence of
13 Dr Reith -- I am looking at WIT 59/10 -- Dr Reith, as of
14 course you know, is the Honorary Secretary of the Royal
15 College of General Practitioners, and he very helpfully
16 assisted the Inquiry on the question of how GPs would
17 choose to refer a child who had, say, a suspected heart
18 murmur on wards. He makes the point at this part of his
19 statement that the majority of children with complex
20 cardiac conditions are likely to be picked up in
21 hospital at birth, and therefore a GP may not see them
22 until they have already come under the care of
23 paediatric cardiologists and possibly even surgeons.
24 We see in the bottom paragraph there that in fact
25 a GP is only likely to see a new patient with such a CHD
0068
1 about once every five years.
2 If we go on to page 12 of his statement, he picked
3 up some of the implications of that by pointing out that
4 the GP is likely to refer the child to a paediatrician,
5 and then, if we can scroll down, you will see, Professor
6 Baum, that in general the likely route of referral will
7 be to a general paediatrician rather than to
8 a paediatric cardiologist.
9 If we turn over to page 14 of the statement,
10 please, he says there that in effect the signals that
11 were being sent out when GPs were referring to Bristol
12 was that it was a major teaching hospital in the UK and
13 funded as such by the Department of Health, and that,
14 looking at 2.2.6, generally GPs would not have
15 information available to them at that time about the
16 performance of particular tertiary centres, but that
17 even if such information were available, it would be
18 difficult for an individual GP to interpret it, and that
19 a GP would therefore rely on the consultant
20 paediatrician for their interpretation of the case mix
21 and the severity of each case within it.
22 With that information as a background, can I ask
23 you, if we take the debate one level up, what
24 information would the paediatrician have, or be likely
25 to have, again, looking at the period from 1984 onwards,
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1 about the competence, performance or services offered,
2 to put it more broadly, by the paediatric cardiologist
3 to whom they were considering referring a child?
4 A. As I see it, there were four steps in the referral
5 process. I will address the heart of your question.
6 The first is -- perhaps there are five steps -- the
7 recognition that all is not well with the child in
8 a hospital, or perhaps after the baby has gone home;
9 being seen by the family doctor.
10 And at that point, just let me make this point:
11 mostly the family doctor will not see a baby saying
12 "I have a pain in my heart" or "I have a terrible heart
13 murmur"; what the general practitioner will see is what
14 the family is seeing: the child not right, vomiting,
15 sweating, not a good colour, these vague things. It
16 would be perfectly within the best of practice for the
17 GP to say, "There is something wrong with your baby,
18 I will send you to a paediatrician", or that might have
19 come, as you have said, directly from the maternity
20 hospital.
21 The paediatrician's job would have been to narrow
22 the problem: this is not a stenosis of the valve that
23 the baby is vomiting, the baby is in heart failure,
24 there is a heart problem. There would have been a time
25 when 20 years ago I would have had the responsibility to
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1 try and identify more exactly what the problem was, but
2 if I am working with cardiologists, I will ask my
3 colleague cardiologist, hopefully in the same hospital,
4 to say, "I have a baby who has poor colour, is vomiting
5 and sweating. There is a loud heart murmur and
6 a thrusting apex speed. I believe this to be
7 a cardiological problem, please will you take over the
8 care?" The cardiologist will then come in, take over
9 the care and make the necessary diagnostic work up and
10 will then form the next step to cardiac surgery with the
11 echos and the catheters in between, so it really is
12 a five stage process.
13 To take your question, what information on the
14 performance of my colleague cardiac surgeons would I be
15 looking at at that time --
16 Q. Well, or cardiologists, because I recognise there is
17 a step between the paediatrician and the cardiac surgeon
18 and it is in fact the cardiologist who is likely to make
19 the c