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FULL TRANSCRIPT

   1                      Day 28, 14th June 1999
   2   (10.30 am)
   3   MISS GREY: Good morning.
   4   THE CHAIRMAN: Good morning, everyone. Good morning,
   5     Miss Grey.
   6   MISS GREY: Sir, today we have the benefit of hearing from
   7     Mr Jackson, the President of the Royal College of
   8     Surgeons. Perhaps I could start by inviting him to take
   9     the stand.
  10        Mr Jackson, I think you have gathered that
  11     evidence is taken on oath in the Inquiry. Could
  12     I invite you to stand to take the oath?
  13           MR BARRY JACKSON (SWORN):
  14           Examined by MISS GREY:
  15   Q. Thank you, Mr Jackson. Could I ask, please, for
  16     WIT 48/1 to be on the screen? Mr Jackson, I think that
  17     must be the first page of a statement that you kindly
  18     provided to the Inquiry. Can we just look, please,
  19     briefly at page 14 of the statement? Is that your
  20     signature that appears at the bottom?
  21   A. Yes, it is.
  22   Q. Are the contents of the statement true to the best of
  23     your knowledge and belief?
  24   A. They are.
  25   Q. Perhaps we could then go back, please, to page 1, where

   1     you set out your qualifications and your status as the
   2     current President of the Royal College of Surgeons for
   3     England. Could you tell the Inquiry, Mr Jackson, when
   4     did you take up that post?
   5   A. July 1998.
   6   Q. So it would be right to say that you, unlike Sir Terence
   7     English whom the Inquiry has already had the benefit of
   8     hearing from, did not have any direct involvement as
   9     President of the College in the events leading to the
  10     de-designation of paediatric cardiac surgery as
  11     a supra-regional service, in 1992 to 1994?
  12   A. That is correct.
  13   Q. It therefore follows from that, I think, that you have
  14     come today to give the Inquiry the benefit of your
  15     assistance on general topics relating to standards and
  16     monitoring relating to the Royal College in those
  17     functions rather than upon the specific events relating
  18     to Bristol?
  19   A. That is correct.
  20   Q. If we could then look towards the end of paragraph 2
  21     of your statement, you set out there the aims and the
  22     legal foundations of the college and you say in
  23     particular that the Royal College of Surgeons of England
  24     is an independent professional body committed to
  25     promoting and advancing the highest standards of

   1     surgical care for patients?
   2   A. Yes.
   3   Q. Those are the general aims of the College. Perhaps we
   4     could look in more detail at its particular functions,
   5     starting perhaps towards the beginning with its
   6     functions in the training of surgeons.
   7        At the bottom of page 2 of the statement you deal
   8     there with the role of the organisation, the College, in
   9     regulating entry to and continued membership of the
  10     profession of surgery. You say in particular that the
  11     award of the FRCS and now the MRCS mark the satisfactory
  12     completion of basically surgical training and fitness to
  13     commence training in the specialty of service.
  14        Over the page, at page 3 of the statement, you
  15     deal with the progress or the monitoring of progress
  16     through specialist training.
  17        About six lines down that paragraph, you speak
  18     about the award of certificates of accreditation, but
  19     you also mention that that certificate was not
  20     a mandatory requirement for appointment as a consultant
  21     surgeon.
  22        Can you help us: how often -- I am looking at the
  23     period of our terms of reference now, 1984 to 1995 --
  24     how often would it be likely that consultant
  25     appointments would be made without that certificate?

   1   A. I cannot quantify that for you in the detail that
   2     I suspect you would wish to have. Nor am I even sure
   3     that I could obtain that information in detail for you
   4     subsequent to today's Inquiry, but I would say that it
   5     was a continuing process over several years whereby
   6     initially the certificate of accreditation was almost,
   7     perhaps, but not quite, disregarded by appointments
   8     committees, and certainly by the trainees concerned, and
   9     then, over a period of years -- it would be difficult to
  10     say how many years, maybe three, four, perhaps -- it
  11     became increasingly the fact that the advisory
  12     appointments committee did look specifically for that
  13     certificate of accreditation before they were willing to
  14     recommend an individual applicant suitable for
  15     appointment to a consultant post. But it was a gradual
  16     process.
  17   Q. Did the process, the evolution you have described,
  18     happen at the same rate across all different surgical
  19     disciplines, or would there be differences according to
  20     the difficulty in filling a particular surgical post?
  21   A. I am afraid I cannot answer that question with accuracy
  22     and with certainty. I suspect, although it is only
  23     a suspicion on my part, that the degree of competition
  24     that existed for any particular post, regardless of the
  25     specialty, the competition for the post may have played

   1     a part in whether or not an individual applicant had
   2     that certificate or not.
   3        You will realise, I am sure, that within
   4     a particular specialty of surgery, competition for
   5     particular posts within that specialty can vary
   6     enormously, depending on all sorts of matters such as
   7     geography, such as perceived status of the hospital
   8     concerned, whether it is a University Hospital, whether
   9     it is a district general hospital, and such like.
  10   Q. You then speak generally about the monitoring of
  11     training by the Royal College and in the documents you
  12     have provided to the Inquiry, you have referred to two
  13     committees which have an important role in setting up
  14     the process of accreditation of training posts and in
  15     monitoring the quality of the training given to trainees
  16     in them.
  17        If we could turn perhaps to page 48 of the
  18     documents in your witness statement, we see there the
  19     constitution and terms of reference of the Joint
  20     Committee on higher surgical training. It can be seen
  21     from the terms of reference -- I am turning over the
  22     page to page 49 -- that the JCHT keeps under general
  23     review the working of the scheme for higher surgical
  24     training programmes and it recommends to the appropriate
  25     college upon the specialist advisory committee's

   1     recommendation the approval of candidates, and in
   2     general, it hears appeals against the decisions of the
   3     SACs.
   4        So it has a general supervisory control over the
   5     functions of the specialist advisory committees.
   6        If we turn over the page to page 50, we see there
   7     the constitution of the specialist advisory committees,
   8     and they contain in particular representatives appointed
   9     by the appropriate specialist associations. Then there
  10     is a list set out of the various SACs, including one in
  11     cardiothoracic surgery.
  12        We see in particular that the work of the SACs,
  13     and turning over the page to page 51, to their terms of
  14     reference, includes drawing up and maintaining a list of
  15     educationally approved posts where programmes of
  16     training can be carried out and the arrangement of
  17     regular inspections normally every five years, or more
  18     frequently when necessary, of programmes and posts where
  19     training is carried out.
  20        That is a brief review from one of the documents
  21     of the terms of reference of those two bodies. We will
  22     turn a little later to some reports that were prepared
  23     by the SAC on Bristol.
  24        We also have a report from the Hospital
  25     Recognition Committee. Can you tell us how that body

   1     links into the two we have just discussed?
   2   A. The Hospital Recognition Committee is run solely by the
   3     Royal College of Surgeons, but part of its complement
   4     would include invited members representing a range of
   5     specialties. It is responsible for monitoring similar
   6     to the Joint Committee on higher surgical training, the
   7     training and the posts for what is known now as basic
   8     surgical training. That is the training that all
   9     trainees receive in the generality of surgery, sometimes
  10     called "common trunk training", before embarking on
  11     a specialist training in one of the nine recognised
  12     surgical specialties such as orthopaedic surgery,
  13     cardiothoracic surgery and such like. It has a very
  14     similar role at basic surgical training level as the
  15     JCHST you have referred to has at higher surgical
  16     training level, and it is responsible also for ensuring
  17     that the training the basic surgical trainee obtains is
  18     suitable and appropriate for them to be eligible to sit
  19     an examination in the generality of surgery, which used
  20     to be called the FRCS and is now called the MRCS.
  21   Q. So if one were looking at the accreditation of teaching
  22     posts and teaching positions within Bristol, one would
  23     be looking firstly at the role of the Hospital
  24     Recognition Committee for basic surgical training, and
  25     then at the specialist level, looking within the field

   1     of cardiothoracic surgery, it would be the specialist
   2     advisory committee with particular responsibility for
   3     that field which would be responsible for the
   4     appropriate accreditation?
   5   A. That is absolutely correct, yes.
   6   Q. Obviously the process of accreditation involves an
   7     assessment of the quality and standards of the training
   8     to be offered to the potential trainee at whatever
   9     level, and it also implies with it, does it not, the
  10     potential for de-accreditation of either training posts
  11     or the teaching position at the hospital if the
  12     standards are no longer met?
  13   A. Yes.
  14   Q. Can I ask you, what would be the formal route by which
  15     either the Hospital Recognition Committee or the SAC
  16     would be able to reach a decision that de-accreditation
  17     of either a post or a trainee or a training programme
  18     was potentially in issue?
  19   A. The process is similar in both committees. Before the
  20     representatives of the committee make their inspection,
  21     they require a great deal of detail to be submitted by
  22     the hospital Trusts concerned and in the case of the
  23     SAC, the specialty concerned, as to the training that is
  24     offered at the hospital that is being inspected, the
  25     facilities that are available, the timetables, study

   1     leave programmes, library facilities and such like.
   2     This is obtained in advance of the inspection.
   3        It is expected that the information provided will
   4     make it apparent that the post was suitable for
   5     continuation approval for training.
   6        When the inspecting team visit the hospital, they
   7     assess according to a pro forma the detail that is being
   8     given to them to check that the detail furnished by the
   9     Trust and the specialty concerned is appropriate and
  10     correct.
  11        They also interview the trainee or trainees
  12     confidentially in the absence of their trainers, the
  13     consultants, to go into detail as to the trainee's
  14     opinion of the training that they have received at that
  15     particular hospital. That confidential interview is
  16     very key. It is confidential and it has been the
  17     experience of the College and of the SACs in the case of
  18     higher surgical training that trainees are very open and
  19     sometimes very critical of certain aspects of their
  20     training and of the post.
  21        The trainers may also be interviewed as well --
  22     indeed, they are -- to get their feedback as to how
  23     things are progressing, any perceived problems, any
  24     deficiencies that the trainers themselves, the
  25     consultants, feel need rectification. Quite often the

   1     trainers are unhappy with some aspects of the facilities
   2     provided.
   3        If at the end of that inspection and the
   4     interviews that take place, the committee is
   5     dissatisfied with any aspect of the training, what would
   6     normally happen -- and I stress "normally" -- would be
   7     that they would make it clear in a written statement to
   8     the Trust concerned that there were deficiencies and
   9     that they would not approve that post for training for
  10     the next quinquennium, but they would wish to reinspect,
  11     reassess the situation within a given period of time,
  12     usually 6 months, sometimes a year, after the perceived
  13     deficiencies have been corrected and they would then go
  14     back and see the post again to check that the
  15     deficiencies that they have noted have been rectified.
  16        In almost every case -- not all, but in almost
  17     every case -- those deficiencies are rapidly corrected
  18     by the hospital concerned, by the trainers concerned,
  19     because they do not wish to lose training status.
  20        Occasionally, it turns out that those corrections
  21     have not been put into place, in which case, in the case
  22     of the SAC, they would recommend to the JCST, the Joint
  23     Committee, that training, the recognition be removed and
  24     in the case of the Hospital Recognition Committee, they
  25     would recommend to their parent committee in the

   1     College, the Training Board, that recognition should be
   2     removed.
   3        Very rarely, a committee may come across such
   4     a situation which would merit instant de-recognition.
   5     That is most uncommon. It has happened. I cannot give
   6     you figures for the SACs. In the case of the HRC,
   7     I think in the last five years it has happened four
   8     times only, after some 4,500 posts have been inspected.
   9   Q. Thank you. We will come back to that, if we may, in
  10     a little detail in a moment, but perhaps I could just
  11     stay with the terms of reference for the SAC for the
  12     moment, because we see there, or we saw on the previous
  13     page, if we could just go back to that, at page 50, that
  14     one of the members of the SAC would be representatives
  15     appointed by the appropriate specialist organisation.
  16        If we are looking at the discipline of
  17     cardiothoracic surgery and that specialism, what would
  18     be the appropriate specialist associations represented
  19     on the SAC in that case?
  20   A. The Society of Cardiothoracic Surgeons.
  21   Q. Any others?
  22   A. No. Not to the best of my knowledge.
  23   Q. Can I just ask you a little bit more about the
  24     specialist associations and their relationship with the
  25     Royal College of Surgeons?

   1        Generally, can I ask, how would specialist
   2     associations come into being in the first instance?
   3     Would that be anything to do with the initiative of the
   4     Royal College, or would that be purely a professionally
   5     led evolution?
   6   A. The latter; it would be professionally led. The college
   7     would have no part in the gestation of a specialist
   8     association.
   9   Q. We have seen, for instance, that some have a very long
  10     history; that from a statement provided to the Inquiry
  11     by the President of the Society of Cardiothoracic
  12     Surgeons, that society, for instance, was established in
  13     1933, would that be typical, too, of some other
  14     specialist associations?
  15   A. The specialty association representing general surgery
  16     antedates that quite considerably. That was founded in
  17     1917, I believe.
  18   Q. So there is no formal relationship between the Royal
  19     College of Surgeons and specialist associations?
  20   A. No formal relationship, although informally there are
  21     very close links indeed, to the extent that on the
  22     Council of the College of Surgeons, we have invited
  23     representatives from each of the nine specialist
  24     associations representing the nine SAC specialties and
  25     within the college buildings, we have the offices of

   1     each of the specialist associations.
   2   Q. Do you have any formal supervisory or monitoring role
   3     within the work of the specialist associations?
   4   A. No.
   5   Q. And informally, how would you, if at all, seek to
   6     influence their activities?
   7   A. By discussion with them, by them being present at our
   8     Council meetings, so they take a full part in the
   9     discussion of all issues within Council. We have no
  10     meetings or no parts of meetings in camera. Also, on an
  11     informal, out of College association, in the workplace,
  12     and many members of Council would be working side by
  13     side with officers of the appropriate specialist
  14     associations. So there is, in fact, a very close
  15     informal relationship.
  16   Q. But I think it must follow from what you have just
  17     said that you would have no role, for instance in the
  18     membership or election of their officers --
  19   A. None whatever.
  20   Q. -- which would be a membership only activity?
  21   A. Correct.
  22   Q. Some of these questions arise from page 3 of your
  23     statement, where you mention briefly that the specialist
  24     associations were involved in the monitoring of
  25     trainees. That is the second line of your statement,

   1     where you mention their role in monitoring the progress
   2     of trainees through specialist training.
   3        The statement itself did not give details of the
   4     nature of that involvement, but can we take it from the
   5     discussion we have just had that the answer lies in
   6     their membership and participation in the specialist
   7     advisory committees?
   8   A. Yes. Certainly. And also, in the joint organisation of
   9     the further specialty examination which is referred to
  10     in line 3, which is the specialty fellowship examination
  11     which takes place towards the end of training, and that
  12     is run jointly by the college and the specialist
  13     association in question, depending on the specialty.
  14   Q. Or did specialist associations have any further role in
  15     the monitoring of standards? I am thinking here
  16     specifically of the advisory appointments committees
  17     which sat on the appointment of consultants throughout
  18     our period.
  19   A. Not formally. The College was responsible for having
  20     a member of the Advisory Appointments Committee, but
  21     although that was a College nominee and reported to the
  22     College, certainly, increasingly over recent years, the
  23     College has tried to ensure that the individual that the
  24     College puts on the advisory Appointments Committee
  25     should also be someone recognised by the appropriate

   1     specialty association, and is almost always a member of
   2     that specialty association.
   3   Q. That means that the specialist associations are, through
   4     their membership of the SACs, through their joint role
   5     of the Colleges in the final examination of specialist
   6     training and through possibly their joint involvement on
   7     the advisory committees, should the nominee of the Royal
   8     College also be a member of the specialist association,
   9     quite closely involved in the practice of particular
  10     specialties.
  11        What mechanics did the Royal College put in place
  12     to ensure liaison with the relevant specialty so as to
  13     ensure that the specialty's knowledge of the discipline
  14     or the activities within a discipline were brought to
  15     the attention and known by the Royal College?
  16   A. That would be done through the inspection process of the
  17     SAC, to which we have already referred, and as the SAC
  18     has College representatives on it, and the report of
  19     each SAC inspection would be reported to the parent
  20     Specialist Advisory Committee in full session, which in
  21     turn would report to the Joint Committee on higher
  22     surgical training, there would be, inevitably, an
  23     overlap, a very close overlap, between specialist
  24     association and College in all these aspects of
  25     specialty training.

   1   Q. I think it follows from that, just to clarify your
   2     answer, that there would not be, within the College, any
   3     person with a formal role as liaison officer for, for
   4     example, the Cardiothoracic Surgeons Association, but
   5     instead, the feedback would be through the Joint
   6     Committees or joint functions of the College and such an
   7     association?
   8   A. That is correct.
   9   Q. We have been talking about the role of the College in
  10     training and you gave us already a preliminary answer to
  11     the question of how the process of de-recognition or
  12     de-accreditation of a training post might take place if
  13     that should be contemplated either by an SAC or by the
  14     Hospital Recognition Committee.
  15        Can I ask, firstly, whether there is any
  16     distinction in the range of sanctions that would be
  17     available to either of those bodies in terms of
  18     de-recognition of a specific post for a trainee,
  19     de-recognition of a trainer, or de-recognition of
  20     a training programme at a hospital as a whole?
  21   A. I really refer back to my earlier answer. The process
  22     would be that if there were perceived deficiencies,
  23     depending on the degree of failure, there would rarely
  24     be recommendation for instant de-recognition, either of
  25     post or trainer. That is very unusual. Much more

   1     commonly, they would point out that they would reinspect
   2     within a short period of time to ensure that
   3     deficiencies had been improved and corrected.
   4   Q. If we look at page 56 of your statement, there is there
   5     an appendix to the general manual on training, an
   6     appendix dealing with the details of the trainer.
   7        It is quite obvious that a number of skills are
   8     required of a trainer who is responsible for the
   9     assessment of a trainee through higher surgical
  10     training.
  11        What process was adopted in order to assess the
  12     skills of those people who were carrying out those
  13     functions?
  14   A. I think the answer to that is that the most important
  15     method of identification of any perceived deficiency was
  16     through the confidential interview with the trainees.
  17     I have already stated that these are confidential and
  18     are very explicit and I have already stated that the
  19     experience of both the Hospital Recognition Committee
  20     and the specialist advisory committees in these
  21     interviews is that trainees are really quite willing to
  22     point out problems that they have perceived.
  23        It may be that this has become more readily
  24     divulged by the trainee over recent years. There was
  25     perhaps the case 10, 15, 20 years ago, very difficult

   1     for me to answer that; but I suspect that they may be
   2     more willing to be explicitly critical of the training
   3     that they now receive than was the case in the past.
   4   Q. So would it be fair to say that the process of
   5     recognising the skills of the trainer would be informal
   6     in the first instance in that one would look generally
   7     at the programme that it was proposed that accreditation
   8     should be delivered for, and generally at the CVs, if
   9     one may put it that way, the experience of the
  10     consultants in a particular unit, and that then one
  11     would rely on feedback from the trainees as the
  12     programme developed, as the years passed, to pick up
  13     particular problems that might perhaps be manifest?
  14   A. Yes. In recent years -- this is quite recently -- we
  15     have actually formalised in the annual appraisals of
  16     higher surgical trainees -- assessments, I should say,
  17     rather than appraisal, forgive me; annual assessments --
  18     that they were asked to fill in a quite detailed
  19     questionnaire relating to the training post which is
  20     confidential to the programme director which is sent to
  21     them.
  22        While it would be true to say when these forms
  23     were first introduced, put in writing, there was some
  24     caution I think by trainees to be overtly critical, that
  25     is becoming less the case now than it was when this

   1     scheme was first introduced.
   2        The other thing that I have not mentioned --
   3     perhaps I should have done, which impinges on this -- is
   4     the logbooks that the trainees all now fill out
   5     meticulously and the logbooks are inspected by the
   6     inspecting teams to see what sort of range of procedures
   7     they have undertaken under supervision, and whether they
   8     have been assisting at a procedure, whether they have
   9     done part under supervision or the whole under
  10     supervision, whether the supervision by the trainer was
  11     with the trainer scrubbed, in other words, present
  12     actually at the operating table assisting the trainee,
  13     or whether the supervision was with the trainer
  14     unscrubbed in the theatre, looking over the shoulder of
  15     the trainee whilst it was going on, rather than actually
  16     being an assistant.
  17        This is also now meticulously recorded and would
  18     be a purchaser/provider part of the inspection process
  19     by the visiting team.
  20   Q. We have talked broadly about de-accreditation and
  21     de-recognition. Is the de-recognition that might
  22     potentially be threatened by the SAC or the Hospital
  23     Recognition Committee something that can take place in
  24     respect of trainers, or can it only take place in
  25     respect of the post at a particular hospital?

   1   A. Both.
   2   Q. What would the mechanics and the effect be of
   3     de-recognising a particular trainer?
   4   A. In the case of basic surgical training a Senior House
   5     Officer. In the case of higher surgical training the
   6     Specialist Registrar, or in days gone by, a career
   7     Registrar or Senior Registrar would not be allowed to
   8     work on the firm or on the service that particular
   9     trainer who had been de-recognised was responsible for.
  10   Q. What effect would that be likely to have on the hospital
  11     concerned?
  12   A. It would make the service cover of the department
  13     increasingly difficult, because there would be less
  14     staff working with that particular consultant so they
  15     might have to rely on locums who were not in a formal
  16     training process to give assistance to that particular
  17     consultant. Or the consultant would work without junior
  18     surgical staff.
  19   Q. You spoke generally of the fact that the Hospital
  20     Recognition Committee had apparently been in a position
  21     to threaten or to de-designate four times summarily in
  22     the past that you were aware of. Can you just clarify
  23     the nature of exactly what took place on those
  24     occasions?
  25   A. Perhaps I could mention two of the four, because I was

   1     personally involved during the past 12 months with two
   2     instances.
   3        This was where the Hospital Recognition Committee
   4     believed that the trainers concerned were unsuitable for
   5     training their Senior House Officers at basic surgical
   6     training level and this was reported back to me
   7     personally as President of the College by the Chairman
   8     of the Hospital Recognition Committee, and I took the
   9     view, given the evidence that had been provided to me,
  10     that instant de-recognition should take place and that
  11     happened.
  12   Q. So we have four examples of instant de-recognition
  13     taking place from the work of the Hospital Recognition
  14     Committee. Is that the entirety of the use of that
  15     power throughout the period from 1984 to the present
  16     day?
  17   A. No. That is within the last five years. I cannot give
  18     you figures previous to five years ago, because I do not
  19     have those available; I did try and look this up for you
  20     before coming here today, but I have not been able to go
  21     back beyond five years. Perhaps I could also say, just
  22     to give you some idea of the quantification, that on the
  23     Hospital Recognition Committee, which I remind you is
  24     purely a College matter, over the last three years in
  25     the order of 5 per cent of posts have been de-recognised

   1     and in the order of 25 and 30 per cent of posts have
   2     been reinspected within 12 months rather than going
   3     through to a 5-year review which would be expected.
   4   Q. So when you were discussing the instant de-recognition
   5     of the two examples you are personally involved in,
   6     those were examples of de-recognition of the trainers
   7     concerned?
   8   A. Yes.
   9   Q. I think you mentioned that you were not able to help us,
  10     today at least, on the extent to which this power has
  11     been used by the SAC in the past?
  12   A. That is correct, yes.
  13   Q. Are either of those two things, either the exercise of
  14     that function by the Hospital Recognition Committee
  15     before the period prior to the last five years, or the
  16     functions of the SAC in the area, matters that you might
  17     be able to help the Inquiry further upon if you were
  18     given more time?
  19   A. I would be very happy to see if we could find further
  20     information on the Hospital Recognition Committee prior
  21     to the last five years, and we could enquire of the
  22     Specialist Advisory Committee or the Joint Committee on
  23     Higher Surgical Training to see if those figures were
  24     available for the SACs. I cannot answer as to whether
  25     that information is available or is not.

   1   Q. I appreciate that, thank you. You mentioned that the
   2     mechanics for the threat of de-recognition would be
   3     a report in the first instance, of course, upwards to
   4     the JCHC or to the College, but that once that step had
   5     been taken and approval at the appropriate level within
   6     the College or the JCHT had been forthcoming, there
   7     would be a report to the Trust Board; is that correct?
   8   A. That is correct.
   9   Q. Can you tell us what the equivalent of that would have
  10     been prior to the institution of Trusts in 1991?
  11   A. It would have been to the Chief Executive, or the terms
  12     then were different. I think they were called at
  13     varying periods of time the General Manager and such
  14     like, but that equivalent.
  15   Q. The nearest equivalent to the hospital General Manager?
  16   A. Indeed, yes.
  17   Q. What about the other bodies within the structure of the
  18     Health Service? Would there be any functional role for
  19     the district authority prior to the introduction of
  20     Trusts?
  21   A. I think it is most unlikely that the College would have
  22     notified the District Health Authority. It may be that
  23     an individual hospital might have done so, but I have no
  24     knowledge of that.
  25   Q. If that answer is true for the period before 1991,

   1     presumably it is even more likely to be so after 1991?
   2   A. Yes.
   3   Q. And the Regional Health Authority: would that have any
   4     function or role, either before or after 1991?
   5   A. I think that is most unlikely. Most unlikely.
   6   Q. Notwithstanding the fact that the Regional Health
   7     Authority, for instance, has a role in planning and
   8     meeting health needs across the region, and if
   9     a particular hospital service is disrupted because the
  10     coverage of junior doctors is affected by
  11     de-recognition, that might have some impact upon local
  12     care?
  13   A. I think it is unlikely that the impact of
  14     a de-recognition of one particular trainer, or one
  15     particular post, would have such a massive effect on the
  16     service provided that it would need to get to regional
  17     level. I would have been surprised had that been the
  18     case. I do not know. It may be that further enquiry
  19     will show that on occasion the region was involved, but
  20     I suspect it unlikely.
  21   Q. As things stand, your understanding is that this is
  22     a matter that would be handled at local hospital level?
  23   A. Yes, it is.
  24   Q. And presumably at a University level involving the local
  25     Post-graduate Deans and so on, as well?

   1   A. Yes.
   2   Q. What would their function be?
   3   A. The Post-graduate Dean is responsible for ensuring that
   4     the educational function of a higher surgical training
   5     post is actually carried out, the educational side.
   6   Q. Can you help us as to the balance between what one might
   7     call the use of the power to threaten de-recognition and
   8     the use of the power to actually de-recognise. How do
   9     the two play together in practice?
  10   A. As I have already stated, the threat, if you use that
  11     term, and it is a slightly emotive term, not one I would
  12     choose to use myself, but --
  13   Q. Would you like to choose an alternative?
  14   A. I know exactly what you mean by that. I think that that
  15     has, as I have said, been very powerful in instigating
  16     correction of perceived deficiencies, and it seems to
  17     work -- it seems to have worked -- very well in almost
  18     but not all instances. As I have said, we have
  19     de-recognised something like, loosely, about 5 per cent
  20     of posts in the last three years at basic surgical
  21     training level, so the threat has not worked in every
  22     instance, but it seems to have worked in most.
  23   Q. If it was an effective threat -- this has really been
  24     implicit in much of what you have been saying, but
  25     nevertheless perhaps you would like to state it -- what

   1     was it about it that made it effective? What did
   2     hospitals fear or would be potentially concerned about
   3     if recognition for posts was removed?
   4   A. I think at a hospital level it would be loss of status,
   5     loss of standing; loss of the better quality junior
   6     staff, whatever that term means. So far as the trainer
   7     was concerned, again, it would mean loss of standing,
   8     loss of face, if you wish, with colleagues, and it would
   9     also mean less able staff to work with the trainer
  10     concerned.
  11        So there would be a great incentive, I think, for
  12     both trainer and hospital to retain recognition of both
  13     trainer status and training post status.
  14   Q. Specifically in paediatric cardiac surgery, if we look
  15     at page 6 of your statement, at the very bottom of that
  16     page you speak about the fact that because trainees
  17     would not be getting significant practical experience at
  18     that stage of their training (years 3 and 4) in
  19     intervening and surgical interventions themselves, they
  20     had, instead, the function -- I am looking at the last
  21     sentence now -- in assisting and providing resident
  22     intensive care cover.
  23        Is that correct?
  24   A. We are now speaking specifically about paediatric
  25     cardiac surgery? Yes.

   1   Q. So at that level, that would be the loss of cover that
   2     might be experienced if de-recognition were to be
   3     threatened or take place.
   4        You have spoken and given us broad details of the
   5     use of the power to de-recognise in the last three
   6     years. Are you able to help us on whether or not the
   7     pattern that you have described during that period would
   8     also be typical of the Royal Colleges and the JCHC, the
   9     SACs's exercise of their powers in the earlier period,
  10     the period of our terms of reference from 1984 to 1995?
  11   A. I cannot give statistics, sadly. I wish I could.
  12     Neither do I suspect I shall be able to find statistics
  13     for that period subsequently to today.
  14        My belief is that it probably was less rigorous at
  15     that time than it is today.
  16   Q. How would "less rigorous" manifest itself?
  17   A. I think it is likely that the percentage of "threats",
  18     if you use that term, that were put out by either
  19     Hospital Recognition Committee or Specialist Advisory
  20     Committee were probably less than the figures I have
  21     already quoted to you, but that is only a surmise on my
  22     part and I have no hard data to support that statement.
  23   Q. If you speak of a lower percentage of threats, and
  24     I appreciate we are using this term although you are not
  25     entirely happy with it, perhaps I could go back to an

   1     earlier question, which was, would you prefer to propose
   2     an alternative?
   3   A. No, for the purposes of this morning, we can continue
   4     using that term.
   5   Q. Very well. If we are using, then, a lower percentage of
   6     the use of that power -- power less frequently used or
   7     threatened -- what would be the reasons behind that
   8     rather less rigorous attitude during that earlier
   9     period?
  10   A. I think, as has been stated to this Inquiry by previous
  11     witnesses, there has been a climate of change in a whole
  12     raft of matters relating to training and approaches,
  13     attitudes and such like, within the profession of
  14     medicine generally, not just surgery but across the
  15     board, over the last 15 years. It is evolving all the
  16     time.
  17        Going back to my own experience as a trainee,
  18     there was no inspection at all at a higher surgical
  19     training level, to the best of my knowledge, when I was
  20     a trainee. There were inspections for approval for
  21     posts suitable for enabling one to take the FRCS
  22     examination, but after that, it was assumed that posts
  23     were satisfactory.
  24        This has changed serially over the 30 years since
  25     that period of time when I myself was a trainee,

   1     thankfully, and rightfully.
   2   Q. So what you are describing there is a gradual evolution
   3     of a rather more rigorous attitude, without, perhaps,
   4     any specific stimulus or reasons for marking out
   5     a change between the period prior to 1995 and the period
   6     afterwards?
   7   A. Yes. I do not think there were specific reasons;
   8     I think there was a gradual appreciation by people such
   9     as myself, trainees such as myself, who had experienced
  10     no apparent rigour on which training posts were
  11     assessed. We knew on the grapevine which were reputed
  12     to be the good posts to apply for and there was hot
  13     competition to apply and obtain a Registrar post at
  14     hospital X or working for surgeon Y, where there was
  15     less competition at hospital Z or surgeon A or B. This
  16     was on the surgical grapevine. I think this was
  17     recognised I think by people at my vintage and people
  18     senior to me over a period of years that this was an
  19     unsatisfactory state of affairs and had to be tightened
  20     up and there has been a gradual process by which that
  21     has been tightened up. I think that has been reflected
  22     in surgery and other disciplines as well. If you did an
  23     interview with the fellow President of the Royal College
  24     of Physicians at London, I think he would argue the same
  25     so far as physician training was concerned over the

   1     25/30 year period.
   2        I do not think there was a specific happening in
   3     the mid-1980s that caused a sudden change in attitude;
   4     I think it was a gradual evolution.
   5   Q. Or the mid-1990s, because I was seeking to establish
   6     whether, if you were drawing a contrast between the last
   7     three years which you were speaking of specifically from
   8     the records we have been able to look at and the earlier
   9     period, whether there was any reason for a watershed or
  10     whether we were talking about a gradual evolution?
  11   A. I think it would be fair to say that at the time these
  12     changes were being talked about and gradually effected,
  13     but not directing these changes, the introduction of
  14     minimal access surgery played a part in focusing the
  15     mind quite acutely. This was "keyhole surgery" by want
  16     of another name, because as is well known, when keyhole
  17     surgery in the field of gallbladder surgery was
  18     introduced in this country in the early 1990s, there was
  19     unfortunately a spate of complications resulting from
  20     the introduction of that particular technique which
  21     focused the mind very acutely. But I would say very
  22     strongly that changes were being talked about and
  23     effected on a gradually evolving basis before the
  24     introduction of minimal access surgery.
  25   Q. Just before going on to the question of accreditation

   1     visits to Bristol, if we could just turn back to an
   2     answer you gave a little while ago when you spoke about
   3     the effects of de-recognition upon either a trainer or
   4     upon a hospital which had to provide a service, you
   5     spoke generally about the threats both to prestige, to
   6     recruitment and to cover that would result from the loss
   7     of training posts.
   8        Would it be too dramatic to say that in some
   9     cases, depending on the number of posts that were at
  10     threat, the de-recognition of those posts could result
  11     in the service that was being provided having to close
  12     down?
  13   A. In theory, certainly. I am not sure that ever happened
  14     in practice.
  15   Q. Because ...
  16   A. Because, if such a post had been de-recognised, there
  17     was another post or posts within the same specialty that
  18     could continue the service work, if I can use that
  19     term.
  20   Q. And what rearrangements might that imply for the
  21     hospital in question?
  22   A. It is difficult for me to answer that in detail, because
  23     I do not know the particular circumstances of particular
  24     hospitals where this applied, but I would imagine it
  25     would be the employment of locum staff who were not on

   1     training rotations to take over some of the service
   2     roles that the trainees would have been undertaking
   3     previously.
   4   Q. So if we were to look, for instance, at the discipline
   5     or the specialty of cardiothoracic surgery, would you be
   6     able to help us on what it would have meant for Bristol,
   7     speaking hypothetically, because as we know and will see
   8     in the documents we are coming to, this was never an
   9     option, but if the cardiothoracic specialty had been
  10     threatened with de-recognition for higher specialist
  11     training are you able to help us as to the likely effect
  12     that might have had upon the service?
  13   A. I imagine what would have happened, although others may
  14     be able to give you a much better answer to that
  15     question, is that they would have advertised rapidly for
  16     locums to take over the responsibility of the trainees
  17     who were no longer working for the surgeons in question,
  18     so that the service work could continue. That is what
  19     I imagine to have happened, but others would be able to
  20     answer that question perhaps more accurately than
  21     myself.
  22   Q. Thank you. If we could turn perhaps to the
  23     accreditation visits that were paid to Bristol, can you
  24     tell us, then, first briefly, what the purpose of visits
  25     either from the SAC to the cardiothoracic surgery

   1     department or from the Hospital Recognition Committee
   2     would be?
   3   A. The purpose would be to assess, as we have already
   4     discussed, the training that the trainees were receiving
   5     at the appropriate levels, and whether the College or
   6     the Specialist Advisory Committee would be willing to
   7     continue recognition of those training opportunities for
   8     the next quinquennium.
   9   Q. Because one of the aspects -- and there are obviously
  10     many -- of the service in which the trainees were being
  11     trained which might have an impact upon the quality of
  12     the training that was being received, would be the
  13     quality of the work, the quality of the surgery, that
  14     was being carried out at the institution.
  15        What role or responsibility would the Hospital
  16     Recognition Committee or the SAC have in looking at that
  17     aspect of the environment in which the trainees were
  18     working?
  19   A. The Hospital Recognition Committee would not principally
  20     be concerned with that, I think, because at SHO level
  21     the Senior House Officers in cardiothoracic surgery
  22     would not be training to become cardiothoracic surgeons,
  23     with very few exceptions. This would be part of the
  24     core training, the common trunk training that I referred
  25     to earlier, gaining a broad experience, and so I do not

   1     think the Hospital Recognition Committee would be trying
   2     to make any formal assessment of the quality of surgery
   3     that was being carried out, although, clearly, it might
   4     transpire during the course of their visit that concerns
   5     were raised with them.
   6        The Specialist Advisory Committee I think should
   7     be more aware of that side of the training inspection.
   8     The confidential interview that I have mentioned already
   9     would perhaps touch on that aspect more than any other
  10     part of the Specialist Advisory Committee's visit. As
  11     these interviews were confidential, it is difficult for
  12     me to say what questions might be asked and exactly what
  13     replies might have been received.
  14   Q. No, I understand that. If we concentrate upon the
  15     Specialist Advisory Committee, if you say that they
  16     should be more aware, speaking generally, of issues
  17     about the quality of service, can you tell us first
  18     whether there would have been any briefing in advance of
  19     an inspection visit by the SAC on general issues
  20     relating to that aspect of affairs?
  21   A. I cannot answer that with certainty, because I do not
  22     know. Certainly, not in cardiothoracic surgery, not
  23     being a cardiothoracic surgeon myself. I think the
  24     probable answer is no, but I do not know that for
  25     a fact. It might be that that is something that could

   1     come out in other evidence, when you speak to those who
   2     took part in SAC visits in cardiothoracic surgery.
   3   Q. I am grateful. Generally speaking, are you able to help
   4     us upon the nature of the preparation that the SAC would
   5     undertake before inspecting?
   6   A. Yes. I refer back to the answer that I gave you
   7     earlier, the information would not relate specifically
   8     to the performance of individual surgeons in terms of
   9     outcome, which is what I think you are hinting at.
  10   Q. Yes, but one could take it more broadly and say that
  11     a process, for instance, of audit had been developing
  12     throughout the years with which we are concerned?
  13   A. Yes.
  14   Q. That the College had, for instance, expressed the
  15     opinion -- we will go to it later in more detail -- that
  16     it would be looking at the records of audit in making
  17     hospital inspections.
  18        What I am asking, I think, is what, if any, data
  19     would be made available to the SAC on these aspects
  20     before it actually visited the hospital in question?
  21   A. I cannot answer that in detail. As you rightly say,
  22     audit information and the regular carrying out of audit
  23     meetings has been part of the inspecting team's remit,
  24     if you wish, certainly since 1990, 1991, or thereabouts,
  25     when audit became more formalised than it had been prior

   1     to 1990/91.
   2        Whether our detailed audit statistics were made
   3     available to SAC teams visiting in cardiothoracic
   4     surgery, I am not sure. Certainly, whether regular
   5     audit meetings were taking place and whether regular
   6     attendance at those audit meetings by both trainers and
   7     trainees occurred would certainly be a part of the remit
   8     of the inspecting team. That was required and
   9     information was made available to them.
  10   Q. It may be, as you indicate, we need to direct our
  11     questions to those directly involved in the
  12     cardiothoracic SAC and I appreciate the help you are
  13     able to give us on this.
  14        If we could turn, then, perhaps to the record
  15     of the first visit that we have, this is at
  16     RCSE file 2/213.
  17        I will take these briefly, if I may, partly
  18     because, Mr Jackson, I appreciate that you yourself had
  19     no part in these inspections -- we see the names of
  20     those who were at the top of this page -- and also
  21     because Sir Terence English has been kind enough to help
  22     us on these as well.
  23        Could I ask you, if we turn to page 216, to note
  24     firstly that under the heading of "Facilities" at the
  25     bottom, the observation there is made that there is an

   1     ITU, a very impressive open unit recently refurbished,
   2     and that adjacent to the ward is the theatre suite with
   3     two dedicated cardiac theatres.
   4        If the Inquiry were to hear later that the theatre
   5     was in fact on a different floor and that patients,
   6     therefore, had to come up from one floor to the other
   7     using a lift before being admitted into the ITU, is
   8     there any observation that you would care to make upon
   9     the quality of the inspection that was being carried out
  10     here?
  11   A. I found that a difficult question to answer. The reason
  12     I say that is that I happen to know, by chance, one of
  13     the two members of the inspecting team. I happen to
  14     know that that particular individual is a very thorough,
  15     conscientious individual.
  16        Had I not known, personally, one of the two,
  17     I would have said, yes, I think it might indicate
  18     a rather slipshod approach, but knowing one of the
  19     individuals personally and knowing his
  20     conscientiousness, I have to ask myself whether this is
  21     a typographical error of some sort that somehow was
  22     wrongly interpreted off a dictaphone or something of
  23     that nature. I do not know the answer, but certainly on
  24     the surface it would seem it was a rather unfortunate
  25     mistake that was made, if mistake it transpires to have

   1     been.
   2   Q. Perhaps I should give you the opportunity to answer more
   3     generally about what your impression is upon the quality
   4     of the work done by SACs, by hospital recognition
   5     committees, in respect of inspection facilities?
   6   A. I can speak with confidence about the Hospital
   7     Recognition Committee because it comes from my College,
   8     and I can say absolutely with certainty that I am
   9     impressed with the rigour with which those inspections
  10     were carried out. I have no reason to suppose the
  11     rigour is not equally true of the SAC visits.
  12   Q. If we pass on to page 219, it may be that this is
  13     something that you cannot comment on because
  14     I appreciate you are yourself not a cardiothoracic
  15     surgeon, but I am looking at the first paragraph of that
  16     page, where the reports on the confidential interviews
  17     are set out to the extent that they do not remain
  18     entirely confidential and the experience of Mr Waterston
  19     is set out there.
  20        We see there that his experience in cardiac
  21     surgery appears very adequate. He is regularly doing
  22     two, sometimes three open heart cases a week, mostly
  23     unsupervised.
  24        I think that is probably a comment primarily upon
  25     adult cardiac surgery rather than paediatric cardiac

   1     surgery, but is that the level of supervision you would
   2     have expected to see?
   3   A. It depends entirely on how experienced this particular
   4     trainee was prior to the inspection. I note that he
   5     is 35; that he has had his Australian fellowship -- this
   6     is a 1989 report, is it?
   7   Q. It is, yes.
   8   A. -- two years. It does not say what these open heart
   9     cases are. I imagine they were fairly straightforward
  10     technically, on the easier side, if I can use that term,
  11     and that he had extensive training supervised prior to
  12     doing these mostly unsupervised operations.
  13   Q. It is obvious that you yourself do not have any
  14     firsthand knowledge of the contents of the report. We
  15     do know that it is fair to say that the inspectors
  16     clearly did not have any concerns because they say
  17     simply that he is obviously a very positive young man
  18     who will do well, rather than recording any form of
  19     adverse comment on the experience that he was having.
  20        If I could turn back to page 217, we see there the
  21     list of the staff at the hospital and the actual weekly
  22     programme is set out, and then, underneath, the
  23     operative commitments of the various consultants.
  24        Mr Wisheart there is listed as having 10 sessions
  25     per week. It is fair to say that if we move on to the

   1     1994 document, as we will shortly, the same finding is
   2     recorded there: 10 sessions a week.
   3        Would you be able to help us as to the freedom
   4     that a consultant who was engaged in 10 sessions a week
   5     in the operating theatre would have had to manage other
   6     commitments such as involvement in clinical audit,
   7     education, self education, and in particular, any role
   8     within the hospital administration, such as that of the
   9     hospital Medical Director?
  10   A. You imply that the 10 sessions of Mr Wisheart and
  11     presumably the other two consultants listed there, were
  12     all in the operating theatre. I think that is most
  13     unlikely. A 10 session appointment is likely to have
  14     only a limited number of operating sessions and other
  15     sessions would be taken in the outpatient department,
  16     for example, on ward rounds and on administration and on
  17     teaching. So I do not know from that information how
  18     many of those 10 sessions of Mr Wisheart, or the other
  19     surgeons, were actually operative sessions.
  20   Q. I see, so it would not be fair to read that as merely
  21     relating to operative?
  22   A. Absolutely not.
  23   Q. Would you be able to help us as to the typical balance
  24     of sessions that we would expect or could expect to see
  25     from a consultant surgeon throughout the period of our

   1     terms of reference, the balance between the various
   2     commitments that you have just described?
   3   A. It constantly comes as a surprise to members of the
   4     public when it becomes known to them that most
   5     surgeons -- I exclude cardiac surgeons, just for the
   6     moment -- probably have no more than three sessions out
   7     of their 10 actually formal elective operating sessions,
   8     because the general public perception is that a surgeon
   9     is in the operating theatre all day every day and that
  10     is what they are doing, but in fact the operating is
  11     only a relatively small part of their weekly timetable
  12     so far as elective non-emergency surgery is concerned.
  13        I think in the field of cardiac surgery, the
  14     cardiac surgeons do seem to spend longer in theatre than
  15     most other branches of surgery and it may well be that
  16     the cardiac surgeons, a rather greater number than 3
  17     would be a regularly expected requirement of them in the
  18     operating theatre, but again this is something you would
  19     need to ask a specialist in cardiac surgery.
  20   Q. What about other time commitments? I think it was
  21     suggested that half a session would be required for
  22     involvement in audit?
  23   A. Yes, it was a recommendation in the 1989 guidelines on
  24     audit, and subsequently.
  25   Q. I think it then went up in 1995 to at least half

   1     a session a week?
   2   A. Yes.
   3   Q. And other involvements? Other responsibilities? Is
   4     there any typical pattern that can be established or
   5     does it vary enormously?
   6   A. It varies from specialty to specialty, but there would
   7     be operating sessions, outpatient sessions, teaching
   8     sessions, almost certainly if students were attached to
   9     the hospital. That might be undergraduate teaching or
  10     post-graduate teaching. There would be
  11     management/administration, if you wish. There could
  12     well be research sessions, depending again on the
  13     particular sort of hospital the practitioner is working
  14     in and nowadays, many specialties have an additional
  15     session for educational activities, particularly if one
  16     is a tutor or holds some educational responsibility
  17     within the hospital concerned.
  18   MISS GREY: Mr Jackson, I am just about, if I may, to pass
  19     on to the 1994 reports, but perhaps that might be
  20     a convenient moment to take a quarter of an hour's
  21     break?
  22   THE CHAIRMAN: Yes, thank you, Miss Grey. We will take
  23     a break now and reconvene at -- would that be noon?
  24   MISS GREY: I think it would, yes.
  25   (11.45 am)

   1               (A short break)
   2   (12 noon)
   3   MISS GREY: Before the break we were looking at the reports
   4     of the accreditation committees to Bristol. If we could
   5     look at RCSE 2/230, this is the next report in time,
   6     a visit by the Hospital Recognition Committee, this
   7     time, to Bristol on 4th May 1994.
   8        Can I ask firstly, would the questionnaire for the
   9     College visit be a document of a type you would be
  10     familiar with, Mr Jackson?
  11   A. No, is the honest answer, because I have not myself
  12     served on the Hospital Recognition Committee, so I have
  13     not had personal experience of going through
  14     documentation that the committee receive before
  15     a visit. But I think in broad terms what it comprises.
  16   Q. Looking at that document, one would assume that was
  17     a pro forma that would be used on a number of visits.
  18     Although that might be a reasonable assumption from the
  19     document, it is not something you can help us on
  20     specifically?
  21   A. This is the information obtained before the visit?
  22   Q. No, this is the questionnaire that has obviously been
  23     filled out as a result --
  24   A. I have seen this one, because I looked at this as part
  25     of the documentation that we submitted to you.

   1     I thought you meant the information required of the
   2     Trust before the visit took place.
   3   Q. No, it is my fault, Mr Jackson. I am not making myself
   4     clear. I was only seeking to find out whether or not
   5     the questionnaire was, as it were, a standard form
   6     document that would be used for other visits as well.
   7   A. Yes, it is.
   8   Q. If one looks at this report, it goes through, obviously,
   9     the posts for which recognition is required and if we
  10     scroll down the page, we can see those. There are
  11     a number of SHO posts under scrutiny there, of which
  12     cardiac surgery is obviously only one of many. Then one
  13     has the name of consultants and then, over the page, at
  14     page 231, it sets out the findings on the specific
  15     specialties looked at, and in particular, if one goes
  16     towards the bottom of the page, the committee is picking
  17     up a problem with consultant supervision and SHOs in
  18     cardiac surgery in particular, because the finding there
  19     is that it is very poor and for paediatric surgery there
  20     is a reference to the report.
  21        If one turns to page 232, there are then findings
  22     about the general status of the related specialties.
  23     Anaesthetics is rated highly. Library facilities and
  24     organisation of duty rosters.
  25        Then, at the bottom, the questions on seminars,

   1     tutorials and audit, and we see there the question
   2     14(c), "Is there any form audit, eg deaths,
   3     complications, meetings", and the record there is "Yes,
   4     (monthly)".
   5        That is the only record I have been able to find
   6     on the subject of audit in that report. I will be
   7     corrected if I am wrong, but I do not think there is
   8     anything further on that subject in the specific report
   9     that was appended to the questionnaire.
  10        Looking at that rather bald summary, it might well
  11     be asked by an outsider whether that was an adequate
  12     assessment of the process of audit and its efficacy
  13     within the hospital at the time.
  14   A. I agree.
  15   Q. What is perhaps a little bit surprising is that the
  16     form itself does not appear to require anything more of
  17     the scrutinisers, the members of the committee, than the
  18     answer to that particular question?
  19   A. In 1994, that was the form that was used for these
  20     visits.
  21   Q. Perhaps you can help us more generally, then. When the
  22     College wrote, as it did, and we have agreed already in
  23     the 1989 paper on clinical audit that attention would be
  24     given to the quality of audit in hospital inspection
  25     visits, what did it mean by that and what did it

   1     envisage would be carried out by way of scrutiny?
   2   A. Like so many of the matters that are being looked into
   3     by this Inquiry, there has been a continuing change over
   4     the period specific to the inquiry and subsequently, not
   5     as I have said before as a specific result of any one
   6     happening, but just generally, there has been
   7     a recognition that change is necessary and that that
   8     change has been part of a continuing evolutionary
   9     pattern and that applies to the matter of audit.
  10        The College first made any formal recognition of
  11     the importance of audit in that 1989 document to which
  12     you refer and I think we furnished you with a copy of
  13     that.
  14   Q. Indeed, yes.
  15   A. There have been updates of that since.
  16        In 1989 I think it would be fair to say that audit
  17     was a very ill-understood beast in the mind of the
  18     profession. It had been around for some years before
  19     that to a greater or lesser extent, but it had been
  20     largely in the hands of one or two enthusiasts,
  21     particularly computer enthusiasts, because audit really
  22     only took off when computerisation of data became easily
  23     available. When one was running audits going back to
  24     the 1970s, one was doing this with handwritten
  25     punch-cards and such like, which was terribly

   1     cumbersome, not very efficient, and did not really play
   2     any major part in current thinking, except amongst a few
   3     enthusiasts.
   4        After 1989 the College stated that they believed
   5     this to be important. Computing was becoming more
   6     easily available. Personal computers were becoming to
   7     be more widely used than they were previously. The use
   8     of computing really took off in the decade subsequently,
   9     but in those early days up until this form in 1994, as
  10     you can see, I think that there was not as close
  11     a scrutiny of audit then as there would be today, for
  12     example, merely because this was an evolutionary
  13     process; the College was using documents that had been
  14     standardised probably two or three years earlier.
  15     I cannot tell you when this particular form came into
  16     use in the College; it would have been probably about
  17     1991/1992, I would guess, when we had a new Chairman of
  18     the Hospital Recognition Committee appointed at that
  19     time.
  20        At that time, in retrospect, certainly so far as
  21     this Inquiry is concerned, perhaps surprisingly, there
  22     was not more enquiry into it formally than what you see
  23     on the form.
  24   Q. So if we just look briefly, to give us our anchor, at
  25     the 1989 document (WIT 48/119), this is not the cover

   1     sheet, just the relevant part of the document. We see
   2     under the heading of "Resources" that clearly the
   3     College was concerned that audit could not be properly
   4     introduced without adequate resources, so it is said in
   5     the second paragraph that the College would insist on
   6     reviewing local facilities to ensure that adequate
   7     management support was available.
   8        It pointed out the need for various forms of
   9     assistance.
  10        If we scroll to the bottom of the page, we see
  11     from the penultimate paragraph that great importance was
  12     attached to inspections by the Hospital Recognition
  13     Committee and that from January 1990, there would be
  14     a routine scrutiny of hospital notes and audit records
  15     to ensure optimum standards of surgical care.
  16        If that was the aspiration from January 1990, can
  17     you help us a little bit more on the reality from
  18     January 1990 to the end of our terms of reference?
  19   A. I think, as I said before, it was an evolving process.
  20     Again, I cannot state with absolute certainty, but
  21     I suspect that what happened in reality was that the
  22     group that wrote the guidelines on audit, which were
  23     largely written by the Audit Committee chaired by one of
  24     our members of Council, Mr Devlin, who was very involved
  25     with audit matters, was done by one group and that those

   1     responsible for the Hospital Recognition Committee form
   2     was another group which perhaps did not actually sit on
   3     the Audit Committee and perhaps the routes of
   4     communication between the two groups were less than
   5     ideal. That is what I suspect might have happened to
   6     explain the apparent anomaly we see on the screen before
   7     us now, in the last paragraph, and the rather sparse
   8     reference to audit we saw on that 1994 Hospital
   9     Recognition document.
  10   Q. Would you like to update the Inquiry as to the position
  11     that would now be the case, because you are talking
  12     obviously about an evolving process?
  13   A. Yes. The inspection and audit facilities and the use of
  14     audit within a hospital Trust when the Hospital
  15     Recognition Committee and the SAC visits were made,
  16     would be almost certainly rather more detailed than was
  17     the case in 1991/92/93. That is the short answer.
  18   Q. If we just go back, then, to the report we have been
  19     looking at, RSC 2/232, that was the form that we saw
  20     there, and we have noted that. It is fair to say, just
  21     to pick up the whole of this report, that if one looks
  22     at page 236, there is further explanation of the comment
  23     that appeared very briefly in the body of the report
  24     about the nature of the training for SHOs who were
  25     unsatisfied except for the experience in teaching in

   1     intensive care provided by the anaesthetist, and so on.
   2     It then goes on to note that in fact "the cardiac unit
   3     has a problem of its intensive care ward being on
   4     a different floor to the theatre, so patients have to be
   5     taken there by the lift", I think it should be.
   6        That endorses the comment I was making earlier as
   7     to the error on the location of the theatre. But just
   8     to pick up the overall picture, if we turn on to
   9     page 239, am I right in reading the overall
  10     recommendations, if we can have the second half of the
  11     page, please, as being a recommendation that the SHO
  12     posts in cardiac surgery, where they have identified
  13     various training problems, are for review within a year
  14     instead of the normal five years?
  15   A. Yes, you are correct.
  16   Q. So to make the obvious point, that is the committee
  17     reacting to the concerns that it had had expressed to it
  18     during its visit?
  19   A. Exactly. Along the lines that I said earlier in
  20     response to your questions, that something in the order
  21     of between 25 and 30 per cent of posts that have been
  22     inspected in the past three years have been recommended
  23     for inspection within 12 months rather than the usual
  24     five years.
  25   Q. If we could then pass on to the last of the visits to

   1     Bristol that year, this is the report this time of the
   2     Specialist Advisory Committee in Cardiothoracic Surgery,
   3     and it is to be found at page 222.
   4        That is the start of the report. It is both to
   5     Frenchay Hospital and the BRI, and Professor David
   6     Hamilton and Mr Dussek, who I think must have been at
   7     that time and still is now, the President of the Society
   8     of Cardiothoracic Surgeons, were the visitors.
   9        If we turn on to page 225, this is the start of
  10     the comments on the Bristol Royal Infirmary as opposed
  11     to Frenchay. The first thing that one does note is that
  12     the facilities are described as being exactly as in
  13     1989, and that the consequence of that appears to be
  14     that the visitors have noted again that adjacent to the
  15     ward is the theatre suite with the cardiac theatres, so
  16     it appears that the mistaken description in 1989 has
  17     been repeated into this report?
  18   A. May interject a question? Which is the correct
  19     description of the facility?
  20   Q. We will hear evidence on it, I am sure, but my
  21     understanding at present and I am sure the Inquiry will
  22     be corrected if it is wrong, is that the theatre is on
  23     a different level; it is a level below the ward 5 so
  24     that patients had to be brought up in the lift in order
  25     to get to the ITU.

   1   A. Thank you.
   2   Q. I think it is fair to say -- Mr Jackson, I know you have
   3     had an opportunity to read this report, but again, we do
   4     not see any formal assessment, or indeed any assessment
   5     of audit within the content of the report.
   6   A. Yes.
   7   Q. So the comments that were being made on the process of
   8     scrutiny of audit would apply equally well to this
   9     visit, would they?
  10   A. It certainly appears to be the case from the report we
  11     have in front of us.
  12   Q. Would it be fair to say that when the College produced
  13     its working paper in 1989, it would not have envisaged
  14     it was merely the Hospital Recognition Committee that
  15     was to be concerned with audit, but it was envisaged
  16     that the SAC would have had a role in scrutinising that?
  17   A. Yes.
  18   Q. Because the question that might be posed is simply this:
  19     it would be the SAC who would be better placed to
  20     evaluate the quality of the audit that was taking place
  21     within a particular specialty, because of their own more
  22     intimate knowledge of that specialty?
  23   A. I would agree with that.
  24   Q. Would that therefore not underline the importance of the
  25     SAC carrying out that form of scrutiny?

   1   A. Yes, it would.
   2   Q. If one then goes on to the report in general, it is fair
   3     to say that it gives the BRI at this present time
   4     something of a glowing report. I am looking in
   5     particular at the bottom of page 225, where it says that
   6     the visitors came away from the BRI very impressed by
   7     the comments of the higher surgical trainees who had
   8     nothing but praise for their tuition.
   9        Obviously there is a contrast there between the
  10     experience of the SHOs and that of the specialist
  11     trainees, but the other point that appears is this: the
  12     visit took place on 8th July 1994. Again, the Inquiry
  13     has not heard detailed evidence as yet of events during
  14     that time, but nevertheless, from the events that
  15     emerged or the evidence that was given at the GMC
  16     proceedings, for instance, it is apparent that some at
  17     least will say that by that time there was a serious
  18     breakdown of communications, to put it no higher,
  19     between at least some members of the anaesthetic team
  20     and some of the surgical team.
  21        Perhaps if I might make good that comment by
  22     putting in front of you a document UBHT 61/6.
  23        The point of the letter is really, in a sense, its
  24     date, Mr Jackson, because this is a letter which is
  25     addressed to the Clinical Director of anaesthesia. It

   1     is signed on this version of the letter, if we could
   2     just scroll through to see the signatories, by four of
   3     six consultant anaesthetists. In fact there are other
   4     versions of the letter in existence that contain the
   5     other signatures.
   6        What it says there is, it sets out concerns over
   7     the arterial switch programme, and asks for a review of
   8     that.
   9        I do not ask you to comment on that letter
  10     specifically, Mr Jackson, or, indeed, upon the events,
  11     but the reason I put it before you is this: that there
  12     would appear to be some considerable concern being
  13     expressed at least by anaesthetists within the
  14     cardiothoracic department, and here only a few weeks
  15     later, we have a specialist visit by the SAC looking
  16     into the same discipline, the same department, and there
  17     is no mention of these troubles, to put it like that,
  18     within the report of the committee.
  19        From the outsider's perspective, the SAC's report
  20     might perhaps be characterised as a dog that did not
  21     bark.
  22        Would you be able to help us on what this contrast
  23     of events, as it were, may say, if anything at all,
  24     about the efficacy of the scrutiny process?
  25   A. First, let me say that I would agree with your

   1     observation that from the outside, there seems to be
   2     a major anomaly. I think that is irrefutable.
   3        The explanation, I can only surmise. I do not
   4     know the explanation. I imagine -- and I am thinking
   5     for the first time, having not seen this particular
   6     letter before, or being aware of its existence,
   7     certainly not in that form -- that firstly this is
   8     signed by four anaesthetists and the anaesthetists, or
   9     members of the anaesthetic department would not have
  10     been interviewed by the SAC visitors; they would only
  11     have interviewed the surgeons and the trainees, the
  12     consultants' trainees.
  13        Secondly, it may be that those individuals that
  14     they did interview did not share the opinion of the four
  15     signatories that we see in front of us. Or at least, if
  16     they did, they did not volunteer that information to the
  17     SAC visitors.
  18        I think I can say no more than that.
  19   Q. Could I press it a little further by asking you this:
  20     there is a great deal in the documentation before us
  21     upon the development of teams and a team-based approach
  22     to care. But perhaps in your answer you have just given
  23     to the Inquiry, we see instead a fairly stark division,
  24     at least potentially, between the consultant
  25     anaesthetists who were probably not interviewed, or

   1     possibly not interviewed, in an SAC visit and the role
   2     of the consultant surgeons.
   3        Is there any lesson that can be drawn about the
   4     extent to which teams were a reality at the time from
   5     these events?
   6   A. I think teams -- how shall I put this. This is
   7     a complicated question. What is meant by
   8     "teamworking"? Well, there is teamworking within
   9     a specialty. Let us take surgery as a specialty. Let
  10     us take cardiothoracic surgery, whereby teams of
  11     consultants work jointly one with another and converse
  12     one with another, perhaps do joint ward rounds, one with
  13     another, discuss mutual problems one with another on
  14     a team basis rather than as an individual taking sole
  15     responsibility, even in the most complex and difficult
  16     and uncertain management decisions.
  17        That is one concept of teamworking, and one that
  18     I think is very important indeed and one which I have
  19     myself participated in throughout my entire career, and
  20     believe to be important, that that is developed further
  21     than it currently is.
  22        Then there is teamworking in the sense that you
  23     mean it, I think, between different specialties with
  24     similar interests for the patient, such as surgeons and
  25     anaesthetists and pathologists, and radiologists, for

   1     example.
   2        That exists to a varying extent, I think, within
   3     the profession, within individual hospitals. Clearly
   4     within the operating theatre, the anaesthetists and the
   5     surgeons have to work quite closely together.
   6        But the concept of a formalising of that team
   7     approach between anaesthetists and surgeons and
   8     pathologists and radiologists per se so far as training
   9     purposes were concerned, has not been something that has
  10     been addressed by my College hitherto, or currently for
  11     that matter, and it may be that this is something which
  12     needs addressing in the future.
  13        Clearly, from the terms of this letter, had the
  14     members of the anaesthetic department been interviewed
  15     on that SAC inspection, concerns might have been flagged
  16     up -- would have been flagged up, I imagine -- so
  17     arguably, you are quite right in your assumption that
  18     perhaps a broader inspection across a range of
  19     inter-related specialties might be appropriate in the
  20     future. But at that time, or currently, that does not
  21     exist.
  22   THE CHAIRMAN: May I interrupt just a second? I do not
  23     think Miss Grey has any assumptions, she just puts to
  24     you a series of observations for your observations.
  25   MISS GREY: I am grateful, Chairman.

   1   Q. You mentioned that had the consultant anaesthetists been
   2     interviewed, they might have raised these concerns --
   3     perhaps they would have done; we do not know and cannot
   4     know. But it is apparent that there were discussions
   5     with at least some of the consultant surgeons and
   6     trainees, and no such concerns were raised with the SAC.
   7        That might imply one or two things: either that
   8     the concerns were not shared by those who were
   9     interviewed and seen, or alternatively, even if they
  10     were appreciated, felt that it was not considered
  11     appropriate to raise them with the SAC when training
  12     recognition was at issue.
  13        Is the second of those hypotheses a possible one,
  14     or indeed a probable one, knowing what you know of how
  15     doctors function and how they think?
  16   A. I find that a difficult question to answer, because
  17     I suppose it would depend on the way in which the
  18     interviews with the trainees were conducted on that
  19     occasion of that specific SAC visit by Professor
  20     Hamilton and Mr Dussek. I do not know the sort of
  21     questions that they asked of the trainees and I suppose
  22     it is possible that one of two scenarios existed: either
  23     they may have asked questions which gave the trainees
  24     the opportunity of expressing concern, or at least
  25     expressing the fact that some had concern, even though

   1     they did not share that concern themselves; or
   2     alternatively, they may have phrased their questioning
   3     in such a way that it would have been difficult for
   4     trainees to have voluntarily expressed their concerns
   5     relating to the anaesthetic perception of the switch
   6     operations. I do not know quite how it went, so it is
   7     difficult for me to be certain, or even to surmise as to
   8     the explanation that you have seen.
   9   Q. Presumably that is not a matter they would have received
  10     any guidance or training on from the JCHC or the SAC
  11     prior to carrying out the visits themselves?
  12   A. They would not have received such training in interview
  13     techniques.
  14   Q. Because the question perhaps for the JCHC or for the
  15     Royal College would be how could one structure the
  16     process of carrying out the hospital recognition visits
  17     in such a way as to capture this sort of information if
  18     it is a matter of individual concern to the visitors?
  19   A. I think that point is well taken. This is the sort of
  20     issue that the College and the specialist associations
  21     and the SACs are currently considering.
  22   Q. And you would not like to help us further on the details
  23     of the current considerations?
  24   A. No. I think that specifically as a result of the
  25     happenings at the Bristol Royal Infirmary to which this

   1     Inquiry is addressing their Inquiry, as a result
   2     directly of that, the Colleges and the specialist
   3     associations are reconsidering all aspects of
   4     inspection, training processes.
   5   Q. Thank you. Perhaps that might be the moment to move on
   6     from accreditation to the point at which a trainee
   7     finishes his training and looks for the first
   8     appointment as a consultant surgeon, perhaps
   9     a consultant cardiothoracic surgeon, but perhaps
  10     another.
  11        The role of the Royal College on the Advisory
  12     Appointments Committees has I think already been briefly
  13     touched upon by yourself in that you do place a nominee
  14     upon such committees. In recent years, at least, you
  15     have sought to ensure that such a person would be
  16     a member of the relevant specialist association, so with
  17     particular expertise in the fields in which it was
  18     sought to appoint someone?
  19   A. Yes.
  20   Q. Can I just ask who, within the Royal College, would go
  21     about making that choice?
  22   A. We have a list of recognised surgeons for this job,
  23     which have been vetted by the College Council, and also
  24     by the appropriate specialist association.
  25   Q. And those people would be put on to a particular

   1     committee as and when need arose for a particular
   2     appointment, or what?
   3   A. Yes, the training board would go down the list and try
   4     not to overload any one particular individual on that
   5     list, and would look for someone outwith the
   6     geographical area of the consultant appointment in
   7     question, but would take names going down the list. Of
   8     course it may well be that the first name approached was
   9     not available on that particular day so you would go
  10     down the list until you found someone on the list
  11     willing to accept that responsibility, but the list
  12     would have been approved by the Council, the College and
  13     also the specialist association.
  14   Q. And that person would be someone who was seen as being
  15     independent in the sense that you sought to choose
  16     someone from outside the geographical area in question?
  17   A. Yes.
  18   Q. Would they have any particular brief or understanding of
  19     their function from the Royal College before going to
  20     the interview process in question?
  21   A. Yes. They would need to be aware of the mechanism of
  22     training that is required by the College to recognise
  23     someone as suitably trained to occupy a consultant
  24     post. That is easier now currently with the certificate
  25     of completion of specialist training which is now

   1     available, and the appointment of the specialist
   2     register, which you will know is now mandatory upon
   3     anyone being appointed a consultant, somewhat easier now
   4     than perhaps was the case before that mechanism came
   5     into being two years ago.
   6   Q. But in any event, they would need a proper understanding
   7     of the competence of the person that was sought to be
   8     appointed?
   9   A. Yes.
  10   Q. Was there any mechanism for feeding information
  11     gleaned from the appointments process back to the
  12     College, if anything should arise, or was the role of
  13     the person on that committee generally seen as being
  14     exhausted once the interviewing process had been
  15     completed and the candidate had been chosen?
  16   A. It was expected that the consultant concerned would make
  17     a report to the training board of the College, hopefully
  18     a very brief report, just to say that they were
  19     satisfied that the individual that had been appointed
  20     was suitable and appropriate for the post in question.
  21        Occasionally, it has to be said, the College
  22     assessor wrote a rather adverse report and believed that
  23     an inappropriate appointment had been made in the past,
  24     sometimes to the extent of being in minority opposition
  25     to the appointment being made. Now, since the

   1     regulations relating to the Advisory Appointments
   2     Committee have been tightened and the College assessor
   3     has a statutory responsibility of being part of the
   4     Advisory Appointments Committee, if they felt
   5     sufficiently strongly that an inappropriate appointment
   6     was going to be made, they could make that committee
   7     non-quorate by absenting themselves from the decision,
   8     and that would make the committee non-quorate and the
   9     appointment could not be made.
  10   Q. Prior to that, if the appointee was in a minority of
  11     one, he or she was capable of being overruled?
  12   A. That is correct.
  13   Q. For how long has the old system been in existence, the
  14     system whereby the Royal College had a role in the
  15     Appointments Advisory Committee?
  16   A. I cannot give you, I am afraid, the exact date that was
  17     introduced, but it would go back, certainly I believe --
  18     forgive me if I misled you, but I believe it would go
  19     back before the terms of the Inquiry, before the years
  20     relating to the Inquiry.
  21   Q. I think it is right to say that Colleges also have
  22     regional advisers as part and parcel of their staff.
  23     Can you help us a little as to their role and function?
  24   A. We have regional specialty advisers in each of the
  25     specialist association defined specialties, and we also

   1     have a supremo, if you wish, within a region who will be
   2     one of those regional specialist advisers who takes
   3     responsibility for the whole of surgery within that
   4     region. These are the old geographical regions. They
   5     are responsible for looking at the job descriptions of
   6     consultant appointments and approving those job
   7     descriptions in conjunction with the Hospital Trust
   8     concerned, and playing a supervisory role in the
   9     educational and training opportunities available to
  10     trainees within their region.
  11   Q. So there would have been regional specialty advisers for
  12     the South West in cardiothoracic surgery, and also
  13     a regional adviser for the South West?
  14   A. Yes.
  15   Q. During the period of our terms of reference?
  16   A. Yes.
  17   Q. I know that the College has very helpfully provided
  18     a number of documents to the Inquiry, we have been
  19     looking at some of them today. I do not know whether
  20     you have had an opportunity yet, because no doubt you
  21     have not requested it, to look at the documentation, if
  22     any exists, from the regional advisers. It may just be
  23     that that might be something that would be helpful to
  24     the Inquiry if the College could see whether there was
  25     anything of relevance in that source.

   1   A. I would be delighted to look into that and if I can find
   2     any material of relevance to forward it on to the
   3     Inquiry. I apologise for the fact I have not done that
   4     already, and my staff have not. I hope that is not for
   5     any want of information for you, but we will do our best
   6     to provide it.
   7   Q. Not at all. The suggestion has certainly not been made
   8     to that effect; it is an ongoing process. We are here
   9     for a while and we are discovering new documentation as
  10     the Inquiry progresses.
  11   Q. The appointment to the position of a paediatric cardiac
  12     surgeon: you have provided documents to the Inquiry
  13     which show, I think, that throughout our period, or more
  14     accurately, at the very tail-end of our period, there
  15     was a new formalisation of the training for potential
  16     paediatric cardiac surgeons.
  17   A. Yes.
  18   Q. At page WIT 48/16, for instance, I think we see a draft
  19     training programme for paediatric cardiac surgery. If
  20     one looks over the page to page 18, at the bottom that
  21     is dated and signed. It is from Mr Stark and dated
  22     30th May 1995.
  23        Are you able to help us on the status of that
  24     document now?
  25   A. Yes. I think Mr Stark's recommendations have been

   1     taken on board by the SAC in cardiothoracic surgery.
   2   Q. So it is not merely a draft; it now reflects reality in
   3     terms of the requirements for training?
   4   A. Yes. There is another document which I think the
   5     College has furnished the Inquiry, which gives you the
   6     most recent information. It is a printed document.
   7   Q. I think at page 21, there is a training curriculum in
   8     paediatric cardiac surgery. Would that be what you are
   9     referring to?
  10   A. Yes. That was part of it. There is another printed
  11     document as well.
  12   Q. It may be that it starts -- certainly it is helpful to
  13     have these clarified -- at page 19, where there is
  14     a suggested paediatric cardiac surgical training
  15     programme, which runs on to page 20 and then to page 21,
  16     where the other document you have seen is.
  17        That is not necessarily the document you were
  18     referring to?
  19   A. It was not the document. I am sorry that I cannot tell
  20     you the title of it.
  21   Q. It is my fault. I will clarify it and we will come back
  22     to that, just to clear it up.
  23        If we could go briefly back, however, to page 16,
  24     to Mr Stark's paper, I wanted to ask very briefly, under
  25     the last paragraph that you can see there, the

   1     recommendation is that the institution should be
   2     performing no less than 400 surgical procedures per
   3     year.
   4        Is it your understanding that that refers to
   5     paediatric cardiac surgical procedures, or is that
   6     a question that should be directed to Mr Stark himself?
   7   A. I would prefer you to address it to Mr Stark, but
   8     reading that, it makes me think it unlikely that any
   9     institution would be performing 400 paediatric cardiac
  10     surgical procedures per year, because to the best of my
  11     knowledge, those numbers do not exist in one
  12     institution. But I would not wish to be authoritative
  13     on that.
  14   Q. We have seen from other documents that you have
  15     provided -- we can look perhaps back at page 20 -- that
  16     recently two surgical posts, or two training posts, have
  17     been accredited specifically for training in paediatric
  18     cardiac surgery. This sets out the position as was then
  19     the case.
  20        If we look perhaps back to your statement, at
  21     page 7, the current position is set out towards the
  22     bottom of that leaflet:
  23        "Two posts have been established rotating for one
  24     year between Great Ormond Street, London and Birmingham
  25     Children's Hospital, to provide specific training."

   1        That, of course, has been the position recently,
   2     but it is, I think, the position outside of the terms of
   3     reference of the Inquiry.
   4        So if we were to go back to the period during the
   5     Inquiry, the position is, I think, described at page 11
   6     of your witness statement at paragraph 18.
   7        Is that the summary of the position, or the more
   8     informal training routes that pertained during the
   9     period of the Inquiry?
  10   A. Yes, it is. Perhaps I could add for your information,
  11     which will not be apparent from the documentation, that
  12     that part of my witness statement was prepared after
  13     consultation with the Society of Cardiothoracic Surgeons
  14     and has been checked and confirmed by them.
  15   Q. Thank you, I am grateful. While we have that
  16     paragraph up, we can just clarify, perhaps, that there
  17     has been a typographical error that crept into the
  18     statement at the third line from the end of
  19     paragraph 18, where it should say, I know, "nevertheless
  20     it cannot be assumed", but there is an extra "not" that
  21     crept in?
  22   A. As the former editor of a surgical journal, I apologise
  23     most humbly to the Inquiry for not spotting that before
  24     I signed the document.
  25   Q. But during the period of the terms of the Inquiry --

   1     I am looking now at paragraph 12 of your statement, back
   2     to page 7 -- the position is there set out that there
   3     might be a general exposure to some aspects of
   4     paediatric cardiac surgery in years 3 and 4 of higher
   5     surgical training, but that advanced paediatric cardiac
   6     surgery was undertaken in years 5 and 6 and there would
   7     be no further formal examination.
   8        If that was the case, how would it be possible to
   9     know whether or not a candidate who had come to the end
  10     of his or her years 5 and 6 was properly competent to
  11     embark upon such surgery?
  12   A. By the regular assessments of that trainee's trainers.
  13     As I think I mentioned earlier in a question, there is
  14     a regular formal annual assessment of higher surgical
  15     trainees in all specialties and there are regular
  16     informal appraisals of those trainees by the trainers.
  17     It is really by the formalised assessment, which is
  18     documented, as well as the appraisals on a less formal
  19     basis that the trainers ensure that the trainee at the
  20     end of six years is appropriate for recommendation for
  21     the Certificate of Completion of Specialist Training.
  22   Q. Looking again at the years of assessment, what is your
  23     assessment, or the College's, of how well that
  24     functioned?
  25   A. To the best of my knowledge, it functioned very well,

   1     because to the best of my knowledge, inappropriate
   2     consultant appointments have very, very infrequently
   3     been made.
   4   THE CHAIRMAN: May I interject a question there? You talk
   5     of the periodic assessment of the trainee by the
   6     trainer. Did I understand you previously to say that
   7     there was no systematic assessment of the trainer?
   8   A. I do not think I said it in those terms, but your
   9     derivation, the implication of what I said was exactly
  10     as you suggest.
  11   MISS GREY: Because one of the problems that might be
  12     experienced by a candidate trying to gain experience in
  13     this field is touched upon at page 6 of your statement,
  14     again, the part with which you had some consultation
  15     with the Society of Cardiothoracic Surgeons.
  16        If we scroll down towards the bottom of that page,
  17     you say there that "trainees would not be expected to
  18     get significant practical surgical experience at this
  19     stage because of the increasing numbers of percutaneous
  20     interventions undertaken by a cardiologist, having
  21     removed some of the low risk procedures from surgical
  22     practice."
  23        Is that a development that was of any particular
  24     importance during the period with which we are
  25     concerned?

   1   A. Others will be able to answer that more accurately than
   2     I, but I believe that percutaneous interventions carried
   3     out by radiologists was increasing steadily from
   4     certainly the late 1980s/early 1990s onwards and of
   5     course has continued apace until today.
   6   Q. Mr Jackson, I think it probably fair if I take from your
   7     answer that the message is that really the question on
   8     the details of training in paediatric cardiac surgery
   9     might be better addressed to, say, Mr Dussek or those
  10     with direct knowledge of it, rather than to yourself.
  11     Would that be appropriate?
  12   A. That would be appropriate, and I have not, in fact in
  13     the expectation that you would be addressing such
  14     questions to Mr Dussek and others, briefed myself in
  15     detail as to exactly what happened then and now, but
  16     only the more general aspects as contained within my
  17     statement.
  18   Q. That is a very fair point; thank you, Mr Jackson.
  19        If we could then perhaps pass on to the more
  20     general topic of continual medical education, or
  21     continuing professional development --
  22   THE CHAIRMAN: Miss Grey, before you do, would it help if
  23     you were to, as it were, sweep up that other point, that
  24     the guidelines you were looking for --
  25   MRS MACLEAN: It may be helpful to refer to that --

   1   THE CHAIRMAN: WIT 48/22.
   2   MRS MACLEAN: It adds a little detail.
   3   A. That is the document to which I was referring.
   4   MISS GREY: If we turn to page 23, it contains guidelines
   5     for cardiac surgery. I think you are saying that would
   6     also include paediatric cardiac surgery?
   7   A. Yes.
   8   Q. Thank you very much. If we move on, then, to the
   9     question of continuing medical education or continuing
  10     professional development, during the period of our terms
  11     of reference again, I think it is accurate to say there
  12     were no formal obligations placed upon a Fellow of The
  13     Royal College of Surgeons or a Member of the Royal
  14     College of Surgeons to take part in such an exercise?
  15   A. That is correct.
  16   Q. So what would the nature of the obligation to keep
  17     oneself up to date as a matter of professional
  18     competence be?
  19   A. It was a moral obligation. That is the short answer.
  20   Q. A moral obligation possibly backed up by the Code of
  21     Practice of the GMC?
  22   A. The answer is yes, although I have to say that I cannot
  23     remember the dates when successive GMC documents were
  24     published, but certainly, the GMC did not figure high in
  25     the minds of most surgeons throughout the time in

   1     question, the Inquiry time.
   2   Q. So the prime concern would be the individual moral or
   3     ethical responsibility?
   4   A. Yes.
   5   Q. Would contracts of employment or job descriptions of
   6     consultants be likely to have contained during this
   7     period any requirements to engage in continuing medical
   8     education?
   9   A. I think it most unlikely, but I cannot state
  10     authoritatively that that was the case, particularly
  11     towards the end of the terms of your Inquiry.
  12     Certainly, in the 1980s, that would not have been in job
  13     descriptions; it may have started creeping in in the
  14     early to mid-1990s.
  15   Q. I appreciate it is difficult for you to answer because
  16     no doubt the practices would have varied locally from
  17     Trust to Trust, at least to some extent, but is it fair
  18     to conclude from the earlier part of your answer that
  19     even if they did, the real pressure that would be felt
  20     by consultants is likely to be the moral and ethical
  21     one, rather than whatever the job description might have
  22     said on the subject?
  23   A. Yes.
  24   Q. If we look at the document HOME 3/124, this is the
  25     document "Working for Patients", the working paper

   1     produced in 1989. The relevant part is at page 134,
   2     where we can see there that the government intention at
   3     the time was that -- I am looking at paragraph 4.7:
   4        "Once satisfactory local arrangements for medical
   5     audit are in place, there will be a need to revise the
   6     new job descriptions that will be held by all
   7     consultants to reflect the new circumstances."
   8        So there was an intention to make participation in
   9     medical audit, as it was then called, a formal
  10     obligation on the part of consultants.
  11        Are you able to help us on the extent to which
  12     that aspiration, as set out in that paragraph, became
  13     a reality?
  14   A. Could I ask again for the date of this document?
  15   Q. I am sorry, this is March 1989, one of the series of the
  16     working papers published by the government in that year
  17     as the precursor of the 1991 reforms.
  18   A. I do not think I can answer your question, I am afraid.
  19     I should be able to, but I do not think I know how
  20     rapidly individual hospitals and Trusts noted that
  21     recommendation by government and actually put it into
  22     their job descriptions. I am sure that that information
  23     could be found out, but I do not happen to know the
  24     answer.
  25   Q. I appreciate that there may well have been considerable

   1     local variation; it may therefore be a change which is
   2     difficult to track.
   3        If one goes then, therefore, to page 140 of your
   4     witness statement, this is a document dated May 1994
   5     which is the College's, if I may call it, introduction
   6     to the subject of continuing medical education, and in
   7     particular, at page 144, we read there the statement:
   8        "All the Colleges are introducing programmes of
   9     continuing medical education with five-yearly
  10     re-certification of participation and satisfactory
  11     completion ..."
  12        Then the details of the techniques or procedures
  13     that are likely to be introduced are set out.
  14        Can I ask you firstly, what was the genesis for
  15     these changes, or for the perceived need to introduce
  16     a formal system of CME?
  17   A. As I said earlier, discussions and debate had been
  18     taking place about these general issues relating to
  19     audit, to CME, in the 1980s, but were stimulated and
  20     perhaps minds focused quite sharply by the introduction
  21     of minimal access surgery in the 1990s in this country,
  22     1991, I think.
  23        This document, which was published by the Colleges
  24     jointly, a Senate document, but largely, I have to say,
  25     our own College document and certainly drafted by

   1     members of my College Council, came out to some extent
   2     in response to the furore over the complications arising
   3     from the introduction of minimal access surgery.
   4     I think that is in fact made clear in the introductory
   5     paragraphs of this document, but not exclusively related
   6     to that minimal access surgery problem.
   7        There was a recognition, and there had been over
   8     some years before, that these matters of audit,
   9     continuing medical education, ensuring that individual
  10     practitioners participated, was an area that needed more
  11     formal adoption than had previously been the case. That
  12     was the background, I think, to this very important
  13     first document on quality assurance that came out of the
  14     College.
  15   Q. What did the debate or furore over the introduction of
  16     keyhole surgery reveal as to the extent or otherwise of
  17     participation of consultants in continuing medical
  18     education?
  19   A. I think strangely that the introduction of minimal
  20     access surgery did not refer specifically to CME. That
  21     was largely as to how surgeons specifically should deal
  22     with new procedures that might be introduced which they
  23     had not been trained to carry out.
  24        As you will know and as is widely known, minimal
  25     access surgery was introduced all over the world, not

   1     just in the United Kingdom, but in all other countries
   2     in a somewhat uncontrolled manner by the profession.
   3     This is true of the United States, of Europe, just as
   4     much as of the United Kingdom. But that was just one
   5     aspect of a raft of aspects relating to standard setting
   6     and insurance that standards were maintained that were
   7     being debated at that time.
   8   Q. I think you have already referred to the fact that this
   9     document came out of that background, and we can see
  10     that, in fact, in the little headings from A to D which
  11     deal with the process of accreditation for carrying out
  12     new procedures.
  13        That is something I would like to come back to
  14     later, if I may, under that particular heading.
  15        If I could take you back to the question which
  16     I was seeking to ask, what assessment would the College
  17     make of the extent to which consultants were already
  18     participating in CME prior to the introduction of
  19     a formal accreditation programme?
  20   A. None, formally.
  21   Q. Nobody was formally engaged in it in so far as nobody
  22     was required to formally notify their engagement in it,
  23     but to what extent did the College believe it was all
  24     chugging along nicely with everybody doing what was
  25     expected of them, or to what extent did they regard

   1     there might be a problem in this field?
   2   A. I do not think the College as such took a formal
   3     position in the early 1990s that continuing medical
   4     education had to be carried out by all their fellows.
   5     There were articles published in the College journal,
   6     for example -- debating articles, discursive articles --
   7     which suggested that these were matters which needed to
   8     be addressed. Really, as a result of these general
   9     discursive discussions, it was recognised that more
  10     objective evidence of keeping up to date was necessary.
  11        There was also, I think, at the time, an
  12     increasing public pressure on this with articles in
  13     newspapers and magazines, possibly even television
  14     programmes -- I cannot remember the detail -- but the
  15     public perception was such that there was at that time
  16     no formalised mechanism of ensuring that consultants
  17     kept up to date in any specialty, including surgery. It
  18     was this groundswell of feeling both within the
  19     profession and without the profession, the public and
  20     the media, that led to the introduction of a formalised
  21     system as recently as 1996.
  22   Q. What was the problem that the discursive articles were
  23     intended to address, because you have suggested in
  24     effect two possible answers: one that the scheme was
  25     purely as a result of the need to identify the public

   1     perception of their being a problem. The alternative
   2     rationale for it might also be that there was in fact
   3     objectively speaking a real problem of whatever size
   4     whereby some people at least did require further
   5     incentives, to put it no higher, to participate in CME?
   6   A. I think one of the factors might have been the
   7     increasing rate of medical litigation, of alleged
   8     under-performance by medical practitioners. Certainly,
   9     it is a fact that the number of cases brought to the
  10     solicitors have increased almost exponentially over the
  11     last 15 years, and I think it became clear that the
  12     proportion of these cases where there was alleged
  13     under-performance, there might have been some
  14     justification for the allegations that were made;
  15     certainly not all, but some.
  16   Q. So that might have been a factor that one was beginning
  17     to recognise that there were problems.
  18        The other thing relates perhaps to audit, which we
  19     mentioned briefly, although not in any detail. With the
  20     increasing use of audit in terms of outcome audit it
  21     became apparent that sometimes outcomes were not as good
  22     as they might have been and this again fuelled the
  23     general discussions that were taking place leading to
  24     a more formalised system of continuing medical
  25     education.

   1   Q. You have mentioned two things there, both of those
   2     relatively recent, the exponential both of medical
   3     negligence litigation and the introduction of audit for
   4     1989/1990 onwards. Does that imply that prior to the
   5     early 1990s there was very limited awareness of the
   6     extent to which consultants were keeping themselves up
   7     to date?
   8   A. Yes. I think the answer to that is probably yes; there
   9     was a limited awareness. I mean, it was, as I said
  10     before, a moral obligation that consultants did keep
  11     themselves up to date and did continue to practice
  12     appropriately, and I think, going back in my own memory
  13     to my perception of things say in the early 1980s, I do
  14     not think I was aware in the early 1980s that there was
  15     widespread under-performance, even in my own branch of
  16     surgery which I knew something about through my
  17     association with the specialist association and through
  18     the networking and the grapevine that exists inevitably
  19     within a particular specialty.
  20        So I think the answer is, no, one was not aware
  21     that there was a major problem, but it gradually became
  22     more apparent as the decade progressed.
  23   Q. From that answer, then, it would seem that there are
  24     limitations to the efficacy of informal professional
  25     networks in revealing problems of under-performance?

   1   A. Yes.
   2   Q. Whether in terms of outcome or keeping up to date with
   3     new professional practices?
   4   A. Yes.
   5   Q. If one then goes to page 151 of this document --
   6     I should give you first the cover to that: it
   7     is WIT 48/148. It is the handbook on Continuing Medical
   8     Education for Surgeons, it is a more recent document,
   9     dated January 1989; we get the date from the bottom of
  10     that page. This now sets out the scheme as is now being
  11     introduced. If we go to page 151, we see there the
  12     current scheme, as I understand it, where the need for
  13     CME is set out in the second paragraph. There is
  14     widespread acknowledgment of the need for CME for those
  15     who have completed formal training, and then,
  16     recognising this, the surgical Royal Colleges, faculties
  17     and specialist associations formally established
  18     a scheme for recording participation in January 1996.
  19        I will not trouble you, Mr Jackson, with the
  20     details of that scheme because they are apparent from
  21     the documents that you have submitted to us, but if we
  22     look down towards the bottom of that page to the
  23     penultimate paragraph, we see there that the document is
  24     setting out the continued arrangements for a structured
  25     system. It is mandatory for all practising surgeons to

   1     participate. "They should appreciate that failure to
   2     participate satisfactorily may have significant
   3     implications for their continuing employment and
   4     professional practice."
   5        Could you explain to us what is meant by that,
   6     because, again, to lay eyes, that would imply that there
   7     would be available to local management or employers some
   8     form of sanction if continuing professional development
   9     were not being properly engaged upon, that that might
  10     not be right?
  11   A. If I may say, Miss Grey, you have picked upon very
  12     astutely a very woolly paragraph in that particular
  13     document, which I acknowledge is woolly and imprecise.
  14        The Colleges have agreed that it is obligatory
  15     upon all practising surgeons, both within the National
  16     Health Service and in the private sector, to participate
  17     in continuing medical education. They have no sanction
  18     at the present moment to ensure that that happens, other
  19     than to remove trainer status, which we were discussing
  20     earlier.
  21        In the private sector, of course, that is of no
  22     sanction whatever, because in the private sector,
  23     trainer status has no relevance and there may be some in
  24     the National Health Service where trainer status has no
  25     relevance either, so the Colleges are in a weak position

   1     at the present moment regarding sanctions.
   2        I think the authors of this document hoped that by
   3     including that second sentence relating to implications
   4     for continuing employment and professional practice,
   5     that at some future point in time employers would demand
   6     that adherence to CME was undertaken and insurance
   7     companies would fail to reimburse private practitioners
   8     if they were not participating formally in CME. Of
   9     course, with clinical governance coming on stream, that
  10     seems a distinct possibility, although it has not yet
  11     been formalised to that extent.
  12   Q. Do I take it from that that the College would in fact
  13     support the inclusion in terms of contracts of
  14     employment, contractual terms which required consultants
  15     to maintain CPD, CME, according to terms of the Royal
  16     Colleges' schemes?
  17   A. The College would support that 100 per cent.
  18   Q. If we go on, then, in that document, we see that the
  19     philosophy at the moment is focusing primarily on the
  20     continuing education of all practitioners, but there is
  21     also a system for identifying and assisting the minority
  22     who fail to participate in CME to the minimum level.
  23        Is a scheme of revalidation or accreditation for
  24     CME which is primarily based upon a five-year cycle
  25     likely to be sufficiently responsive to those who fail

   1     to achieve certain minimal standards?
   2   A. No.
   3   Q. How, then, will the scheme guarantee that that result
   4     can be achieved?
   5   A. You will notice -- you highlighted, I think, in fact, on
   6     the front page that the scheme may be subject to
   7     modification before the Year 2001. I think this touches
   8     upon the question that you have asked, because it is
   9     recognised by the Colleges that the present scheme is
  10     not a perfect scheme and that it does require amendment
  11     and will require amendment before the 5-year cycle is up
  12     in 2001.
  13        There is a very active committee on CME now called
  14     CPD, as you quite rightly mentioned, looking as to how
  15     the present scheme can be improved and become more
  16     meaningful, and ensure a better system than is outlined
  17     in this particular document. This is being worked on at
  18     the moment. I cannot tell you the outcome of those
  19     discussions, but what I would say is that I think that
  20     the process of CME/CPDs by the Year 2001 will be rather
  21     better and more refined than it currently appears in the
  22     document on the screen before us.
  23   Q. So this should be regarded perhaps as a transitional
  24     document?
  25   A. It is very much a transitional document.

   1   Q. Perhaps that does appear also, to complete the story,
   2     over the next page, page 152, where the document picks
   3     up also the need for developing a more rigorous
   4     qualitative exercise in measuring or monitoring
   5     competence and that that might have some bearing and be
   6     tied into schemes of CPD and CME?
   7   A. Yes, that is correct.
   8   MISS GREY: I wonder whether that might be an appropriate
   9     moment to break for lunch?
  10   THE CHAIRMAN: Yes, Miss Grey. Thank you. Thank you also,
  11     Mr Jackson. We will break now, it being 1.15, and
  12     reconvene at 2.00.
  13   (1.15 pm)
  14            (Adjourned until 2.00 pm)
  15   (2.00 pm)
  16   MISS GREY: Mr Jackson, we were going to turn to the subject
  17     of clinical audit in a little bit more detail.
  18        Perhaps I might start by asking you to help us on
  19     the definition of "audit" throughout our period. It
  20     might help if I asked you to look firstly at the working
  21     paper on medical audit that we have already looked at
  22     briefly, at HOME 3/127.
  23        We have seen the front page already. That was the
  24     document dated March 1989. I can go back to the title
  25     sheet if that would help.

   1   A. No.
   2   Q. In that case, if we could just go down the page
   3     a little, we get there at 1.1:
   4        "Medical audit can be defined as the systematic
   5     critical analysis of the quality of medical care,
   6     including the procedures used for diagnosis and
   7     treatment, the use of resources and the resulting
   8     outcome and quality of life for the patient."
   9        That was the government's definition at that
  10     time. There is a bit more at the bottom of page 128,
  11     where we see there that further development in methods
  12     of audit are needed.
  13        If we turn over the page, there the government
  14     refers to the need to develop a comprehensive set of
  15     measures of the outcome, and talks about the risks of
  16     introducing audit as well the benefits.
  17        With that document in mind, perhaps we could turn
  18     back to the Royal College of Surgeons paper, the
  19     guidelines to clinical audit and surgical practice,
  20     which is at WIT 48/116.
  21        If we turn over the page to 117, we have there the
  22     College's definition of "audit". It is halfway through.
  23        "Audit is the systematic appraisal of the
  24     implementation and outcome of any process in the context
  25     of prescribed targets and standards."

   1        If you have in your mind still the previous
   2     definition that we were offered, these two differ
   3     a little in that the Royal College has put in explicitly
   4     the question of prescribed targets and standards.
   5        Can you help us as to the importance that was
   6     attached to that in defining audit? If it would help,
   7     we can put the two documents up side by side.
   8   A. I do not think that is necessary. I think at the time
   9     these documents were written there was no clear
  10     understanding amongst everybody as to a uniform meaning
  11     of the term "audit". I do not know who wrote the
  12     government document that you put up on the screen first;
  13     I do know who wrote this document. It emanated from the
  14     College.
  15        I also know that in the minds of surgeons and
  16     other doctors, not just surgeons, throughout the
  17     country, there was enormous confusion as to what audit
  18     actually was and how it should be used, and its
  19     importance.
  20        There is no doubt at all in my mind that the
  21     definition that you see on the screen currently is the
  22     correct definition of "audit", that is to say, it is
  23     a systematic appraisal or analysis, if you wish, of any
  24     particular process in the context of a prescribed
  25     standard which has been set, a comparison of what is

   1     actually being done against that standard or target
   2     which has previously been identified, and that should
   3     there be a disparity, then measures should be put into
   4     place to rectify the disparity, or alternatively, to
   5     change the standard or the target which might of course
   6     be incorrect.
   7        You will see subsequent to that sentence the
   8     second paragraph:
   9        "Clinical audit is the process by which medical
  10     staff ..."
  11        The government document that you put on the screen
  12     referred to "medical audit".
  13        I think that some of the confusion may have arisen
  14     between these three terms, "audit", "medical audit", and
  15     "clinical audit."
  16        I say no more than that because I think it was
  17     a very confused area. I think it is still confused to
  18     some extent in the minds of many, even today.
  19   Q. A number of points there. The first, and a minor one:
  20     can you help us as to the author of that document?
  21   A. The one on the screen now? Mr Brendan Devlin.
  22   Q. He would have been, would he, the head or chair of the
  23     audit surgical unit?
  24   A. Yes.
  25   Q. So he might be the one to approach if the Inquiry wanted

   1     further assistance on the work of that unit. Would that
   2     be appropriate?
   3   A. Very sadly, I have to tell the Inquiry that he died some
   4     6 months ago. It was prematurely and unexpectedly of
   5     advanced malignancy. Had he not done so, I am sure he
   6     would have been delighted to have come to the Inquiry
   7     and would have been able to give a very much more
   8     knowledgeable answer on any aspect of audit than I am
   9     able.
  10   Q. My apologies, but perhaps there might be people who can
  11     speak to the work of the unit, if appropriate?
  12   A. We have a director -- our audit unit now is called the
  13     "Clinical Effectiveness Unit" because we are
  14     particularly interested in the effectiveness of clinical
  15     procedures, surgical procedures, and I am sure that
  16     should you wish it, the director of that unit would be
  17     available to speak to the Inquiry.
  18   Q. You have helped us on the definition of "audit". Can
  19     I ask you how the understanding you have of audit
  20     differs from that of the field of quality assurance?
  21     How do the two relate? What are the differences between
  22     them?
  23   A. That is a difficult question to answer. "Quality
  24     assurance" is a jargon phrase which is widely in
  25     evidence at the moment. I think it just refers to the

   1     broad field of quality in its entirety. Audit I think
   2     will be one aspect of a method of trying to ensure
   3     satisfactory quality, but there would be others such as
   4     the CME and CPD, for example, that we were discussing
   5     before lunch, examinations and other aspects of ensuring
   6     quality.
   7   Q. What about the process of review of cases or a series of
   8     cases that perhaps had been undertaken by surgeons ever
   9     before the March 1989 guidelines were published?
  10   A. Yes, well, case reviews, case analyses, were of course
  11     in widespread use and were the subject of many articles
  12     in the surgical literature going way, way, beyond the
  13     dates of this Inquiry. These have very often been some
  14     of the early papers that surgeons in training write
  15     because they are relatively easy to collect the data.
  16     These are not research papers in the true meaning of
  17     research. A retrospective analysis of case series.
  18   Q. Earlier in the Inquiry we had some discussion of
  19     a document UBHT 61/161. If we could have that on the
  20     screen, please?
  21        This is the specialty of paediatric cardiology
  22     undertaking in March 1992 something which is a report to
  23     the Medical Audit Committee, or rather, a report on the
  24     Audit Committee's standard form, and if we look down the
  25     page, the audit topic or criterion reviewed is the

   1     paediatric cardiac surgical mortality for 1991 and
   2     comparisons to previous years.
   3        When Dr Roylance was shown that document in his
   4     evidence to the Inquiry, he gave his evidence that he
   5     regarded this exercise as simply being a review of
   6     recent outcomes and a very valuable one, but not
   7     something that constituted audit within his
   8     understanding of the term.
   9   A. In the strict meaning of the term, I would agree with
  10     Dr Roylance, as I said earlier, because there is no
  11     standard set there with which to compare the mortality
  12     other than previous years, but there is no acceptance
  13     written there that the previous years' figures are the
  14     standard to which they were judging the current year
  15     standard.
  16        So strictly speaking, I think Dr Roylance is
  17     correct in his analysis.
  18   Q. So what happens, then, if a standard is used in the form
  19     of national indicators of outcomes, drawn perhaps from
  20     the exercise of the cardiothoracic surgeons register.
  21     Does it then become audit in the formal sense?
  22   A. If it has been defined and agreed initially that that is
  23     the standard to which one is aspiring, yes.
  24   Q. But no doubt a discussion would have to go through all
  25     the difficulties in using the national data as an

   1     appropriate standard?
   2   A. Yes.
   3   Q. If we then return, perhaps, to the College's paper in
   4     1989, you have spoken of the importance of prescribed
   5     targets and standards. Can you help us as to the extent
   6     to which appropriate targets or standards were
   7     recognised to be available in 1989 and onwards?
   8   A. Very simply, very largely, they were not available.
   9     This is the perceived weakness of audit at that time; to
  10     some extent, still today.
  11        The setting of the standards have created
  12     considerable problems in many areas, and in 1989/1991
  13     those standards in most instances were not recognised;
  14     therefore, to all intents and purposes, they did not
  15     exist. This is where I think some of the confusion has
  16     arisen as to what one is meaning by "audit" because so
  17     often what was perceived as audit -- and I have to say,
  18     going back to the HRC and the SAC visits which we were
  19     talking about this morning, the audit that they were
  20     looking at was probably not audit in the true sense of
  21     the word; in other words, comparing against an accepted
  22     standard.
  23   Q. If standards were not or had not been set or were not
  24     accepted during much of the period we are concerned
  25     with, if not all of it, does it follow then that it was

   1     left for local clinicians to decide what standards they
   2     wished to use in measuring their own performances or
   3     procedures or practices in any hospital?
   4   A. I think that is an inevitable conclusion.
   5   Q. It may be that management might have had some role in
   6     that, but perhaps not.
   7   A. I think at the time we are talking about, it would be
   8     most unlikely that management would be involved in what
   9     was called "medical audit" or "clinical audit". Indeed,
  10     one of the concerns of many hospitals up and down the
  11     country when these meetings were instigated in the late
  12     1980s and early 1990s was that management should not be
  13     party to them and that this was a confidential matter
  14     between the clinicians concerned. You will notice the
  15     stress laid on confidentiality in the document that you
  16     have on the screen at the moment, on another page, and
  17     subsequent College guidelines.
  18   Q. I think we will, if I may, come back to the subject of
  19     management involvement in this, if at all. But does it
  20     follow from the fact that standards or audit topics were
  21     generally set by local clinicians that there could have
  22     been very few opportunities for comparison of audit
  23     exercises from one hospital to another?
  24   A. Yes, it does follow.
  25   Q. Is that something that has changed or improved in any

   1     way in the period with which we are concerned?
   2   A. Sadly I have to say in my opinion only very slightly
   3     improved. I hope and very much anticipate that it is
   4     going to improve considerably in the years ahead.
   5   Q. One has at the time some national enquiries, the
   6     National Confidential Enquiry into Peri-operative
   7     Deaths, for instance, taking place on the one hand and
   8     on the another it might be thought a series of local
   9     initiatives with very little co-ordination or ability to
  10     compare results from one place to another. There seems
  11     to be no middle ground between those two?
  12   A. I think that is true.
  13   Q. If we go back to the paper, then, we see that consultant
  14     surgical staff, at the bottom of the page, are
  15     ultimately responsible for initiating clinical audit.
  16        If we turn by comparison to the 1995 version of
  17     this document also from the Royal College of Surgeons,
  18      RCSE 1/51, there is there possibly a slightly stronger
  19     wording used:
  20        "Consultant surgical staff are responsible for
  21     clinical audit. As responsibility for the care of
  22     patients rests with individual consultants, audit must
  23     be one of their prime concerns."
  24        Does the change in terminology between those two
  25     editions reflect any perceived need to strengthen the

   1     requirement on consultants to participate fully in
   2     clinical audit?
   3   A. Yes.
   4   Q. What experience did that derive from? What had been
   5     the College's experience?
   6   A. Sadly, it was the experience that too few consultants
   7     were actually acting on the guidelines laid down in 1989
   8     and that audit meetings were not always taking place to
   9     the extent and frequency which the College would
  10     recommend and therefore, these guidelines were
  11     strengthened.
  12        I come back to the matter I spoke about this
  13     morning, that these matters were very much an evolving
  14     happening and that in the mid-1980s audit did not take
  15     place at all in any formal sense. It gradually came
  16     on. It is perfectly fair to say that and widely known,
  17     to the considerable resistance from some surgeons and
  18     some other consultants in the early days when these
  19     matters were being introduced. It was only during the
  20     1990s, mid and towards the latter part of the 1990s that
  21     this became a totally accepted part of consultant
  22     practice.
  23   Q. What was the reason for that resistance, or reasons,
  24     perhaps?
  25   A. It was thought to be time-consuming and not particularly

   1     useful.
   2   Q. Were there possibly also doubts on the role or potential
   3     involvement of management in the exercise?
   4   A. No. I think not, because management did not play any
   5     part of it in the early days, and I am not aware that
   6     there was particular resistance on the grounds of
   7     potential management involvement. It is certainly not
   8     something that I am aware of.
   9   Q. If we could go back to the original document,
  10     WIT 48/118, that is the second page of the 1989
  11     version. There we see the stress that you have already
  12     touched upon on confidentiality and the importance of
  13     maintaining confidentiality of the data to the group
  14     participating in clinical audit.
  15        That I think again is something which has not
  16     changed in fact at all in the 1995 edition. The stress
  17     is identical. Can you tell us why that was thought to
  18     be important?
  19   A. I think two reasons, probably. One was the concern
  20     regarding potential litigation, should details of
  21     individual cases become known outside the immediate
  22     confines of the audit meeting; secondly, it was as an
  23     encouragement for frank and open and honest reporting of
  24     complications or lack of the highest standards of
  25     performance that might on occasions have been the case.

   1   Q. Is the College's view still that those two reasons are
   2     as valid now as they were in the College's eyes in 1989
   3     and 1995, or has there been any further development of
   4     thinking on the point?
   5   A. I think there has been a cultural change amongst
   6     surgeons in regard to the openness with which
   7     complications and deaths, some of which perhaps arguably
   8     should not have occurred, are discussed in these
   9     meetings. At one time there was considerable inhibition
  10     about open discussion amongst some, but not all
  11     surgeons. I think that inhibition is markedly less
  12     today than it was in the early days of these meetings.
  13   Q. But does that mean that surgeons have been reassured
  14     because confidence has not been breached, or is the
  15     removal or relaxation of inhibitions a reason to rethink
  16     the requirements of confidentiality?
  17   A. I think the confidentiality still remains, and I think
  18     surgeons have been reassured that to the best of my
  19     knowledge litigation has not ensued as a result of these
  20     meetings. I am certainly not aware of that. So, yes,
  21     confidence has been gained to some extent -- well, to
  22     a large extent -- on that particular score.
  23        Your other point was ...
  24   Q. I was seeking to explore whether the fact that that
  25     confidence had been gained might be used as a reason to

   1     lift or to relax the requirements of confidentiality to
   2     impose in particular further duties upon those who
   3     became aware as a result of audit of problems in
   4     standards and procedures, to bring them to the attention
   5     of those outside the audit group?
   6   A. I think that is going to happen under the government's
   7     clinical governance scheme and that audit -- meaningful
   8     audit -- which will be an essential part of that will
   9     become available to Clinical Directors and Medical
  10     Directors, who are, of course, medically qualified but
  11     who are part of management, have a dual role and to that
  12     extent, management will have access to the data
  13     provided.
  14   Q. I think it is fair to say, also, that the Royal
  15     College's own document on a surgeon's duty of care in
  16     1997 -- published in 1997, RCSE 1/120, also dealt with
  17     this subject in so far as addressing generally the
  18     subject of potentially harmful surgeons and surgical
  19     environments, it looked at a number of duties. If we
  20     scroll down the page, in particular it said, in the last
  21     bullet point, that surgeons or colleagues were "required
  22     to take appropriate remedial steps to bring performance
  23     to an acceptable standard where audit reveals that the
  24     existing standard of a surgeon's care is consistently
  25     unacceptable. If necessary, these steps must be

   1     initiated by surgical colleagues."
   2        So there was clear guidance provided by the
   3     College in 1997 on that obligation. Are you aware how
   4     that would have been perceived or how this whole
   5     territory would have been regarded prior to the issue of
   6     that guidance?
   7   A. I am sure it varied from institution to institution.
   8     There were instances where substandard or believed
   9     substandard surgical practice came out of audit meetings
  10     and perhaps the informal grapevine that exists
  11     inevitably in any institution, certainly in hospitals,
  12     led to these concerns being expressed to a wider
  13     audience -- to the College, in fact.
  14   Q. To the College, the Royal College?
  15   A. Yes.
  16   Q. One thing that is not entirely clear from the guidance
  17     we have seen so far from the College is what the proper
  18     role of management would be if there were concerns about
  19     outcomes. If we could just turn back, please, to
  20     WIT 48/118, we are back in the 1989 document. We see
  21     there under the heading of "Confidentiality" that
  22     hospital management will have access to the general
  23     conclusions of clinical audit meetings.
  24        There is then a reference to paragraph 5, which is
  25     set out below, if we could just see the whole of that

   1     paragraph. I think it is fair to say that paragraph 5
   2     does not really help us enormously, if at all, on the
   3     detail of what was meant by "general conclusions of
   4     clinical audit meetings."
   5        What would your understanding have been as to
   6     the entitlement of hospital management to see anything
   7     arising out of clinical audit?
   8   A. These meetings arose out of what used to be called
   9     initially "deaths and complications meetings". Then the
  10     name changed to "morbidity and mortality meetings",
  11     whereby surgeons discussed solely the complications that
  12     might have arisen during the month in question and
  13     deaths that had occurred during that time -- discussed
  14     them in a general way to see if any lessons could be
  15     learned from them.
  16        The audit meetings that were introduced in the
  17     late 1980s widely tended to occur at the same time.
  18     The morbidity and mortality meetings became the audit
  19     meetings, and given that it was a half a session, as we
  20     discussed this morning, the morbidity and mortality part
  21     of it might have taken up the first 45 minutes to an
  22     hour, and then one moved on to a specific topic which
  23     was largely related not to clinical standards but to
  24     other aspects of hospital activity, such as waiting
  25     lists, such as length of stay, such as operations

   1     cancelled, such as medical staffing problems, and it was
   2     these conclusions or recommendations relating to what
   3     I can term "non-outcome studies", that tended to be fed
   4     back to management, and used as a lever to try and ask
   5     management to improve facilities so that a higher
   6     standard of performance could be carried out by the
   7     surgeons on the ground floor.
   8   Q. Because, to put it crudely, audit could be used as
   9     a tool for obtaining better resources or further
  10     resources from management?
  11   A. Yes.
  12   Q. But if one looks at, again, the government document,
  13     the working paper that we have looked at before, at
  14     HOME 3/130, this time, what was being said there was
  15     that the system had to be medically led and that the
  16     overall form of audit should be agreed locally between
  17     profession and management. Then (d) reasserted the
  18     principal of confidentiality but it went on to say that
  19     the general results needed to be made available to
  20     local management "so that they might be able to satisfy
  21     themselves that appropriate remedial action was taken
  22     where audit results revealed problems."
  23        To what extent did that aspiration, if I can call
  24     it that, become reality from 1989 onwards?
  25   A. I find it difficult to answer that authoritatively.

   1     I know of no statistics. My impression would be that it
   2     happened to a relatively little extent, other than in
   3     the way that I described earlier in relation to
   4     facilities, which I think was relayed repeatedly to
   5     local management in terms of sorts of things such as
   6     waiting lists and theatre availability and such like.
   7     But not, in my opinion, very largely in regard to
   8     performance of individual surgeons.
   9   Q. One does not necessarily need to look at the performance
  10     of individual surgeons; there may be other problems on
  11     quality of outcome revealed by audit which do not
  12     necessarily impact on an individual's performance.
  13     There may be a wide series of difficulties thrown up.
  14     I did not intend to suggest in any way that that was the
  15     only thing I was looking at.
  16        But would it be fair to draw from your answers the
  17     conclusion that there were not generally very clear
  18     protocols as to what went up to management and the
  19     result was that it was for the clinicians largely to
  20     determine what information was passed up the chain in
  21     order, perhaps, to support a case for particular changes
  22     to be made within a hospital?
  23   A. Yes. I think that is a fair analysis.
  24   Q. Looking generally at the subject of audit during our
  25     period, there is a document produced by the British

   1     Medical Association which they refer to in their
   2     evidence, BMA 1/37.
   3        This is the title page. It is a general
   4     discussion document, "Making self-regulation work at
   5     a local level."
   6        It is a 1988 (sic) document.
   7        If we turn on to page 41, the judgment set out in
   8     the second paragraph there is that clinical and medical
   9     audit has, despite the enthusiasm for its introduction,
  10     largely failed.
  11        Then they go on to set out an analysis of
  12     inadequate markers or standards against which work can
  13     be audited and draw attention to various other problems.
  14        Can I ask you for the judgment of your College
  15     upon the failure or success of audit from 1989 to date?
  16   A. You mentioned this was a 1998 document?
  17   Q. 1998.
  18   A. 1998, not 1988, yes. I would agree with the second
  19     paragraph.
  20   Q. What would be the judgment at today's date?
  21   A. One year later? Very much the same as one year ago, or
  22     less than one year ago. This actually came out just
  23     towards the end of 1998, after the government White
  24     Paper came out.
  25   Q. If we could leave that topic, I will pass back to

   1     a document we have seen before, page 144 of your witness
   2     statement, to which I said we would return on the
   3     subject of learning curves.
   4        You have seen page 140 already. This is the
   5     document dated May 1994, produced by the Senate of the
   6     Royal Surgical Colleges on quality assurance in general.
   7        What was set out there, in this document, which
   8     you have told us already was in part at least a response
   9     to the problems thrown up by minimal and basic surgical
  10     procedures, if we look at (a) onwards, we can see there
  11     that in effect two different problems are identified, or
  12     two issues are identified in relation to the
  13     introduction of new surgical procedures.
  14        The first may be the problem of identifying a new
  15     technique, which is something sufficiently radical to
  16     constitute a new procedure. The second is that of
  17     training in that new procedure.
  18        The proposal that was set out, the suggestions
  19     were set out firstly there that new techniques had to be
  20     detected through literature, communication and
  21     conference reviews when they were first made public.
  22        How was it proposed that that could be done in
  23     such a way as to distinguish between the new procedure
  24     and the development of the old?
  25   A. If you look in (b) it says "the Colleges are now

   1     devising the mechanisms for achieving such control."
   2        They did this by setting up the Safety and
   3     Efficacy Register, New Interventional Procedures, SERNIP
   4     for short, which was developed in the 12 months after
   5     this document was published. It was actually formalised
   6     at the beginning of 1996, and widely publicised amongst
   7     purchasers, Trusts, clinicians, specialty associations
   8     and such like, whereby new techniques should be referred
   9     to this new body, SERNIP, for careful assessment as to
  10     whether or not this was a technique that could be
  11     recommended to Trusts and purchasers for widespread
  12     implementation, or whether it needed further refinement,
  13     proper controlled trial assessment, or whether it was
  14     found wanting.
  15        This body, SERNIP, has now been working for three
  16     years and has, by common consent, been reasonably --
  17     I say "reasonably" rather than "wholly" -- successful in
  18     its aims and objectives. Only "reasonably", because it
  19     has not always had everything referred to it for
  20     assessment. It is a voluntary system of referral, and
  21     there have been one or two things that have just not
  22     been referred to it, but by and large, it has worked,
  23     I think, terribly well and its funding, which is
  24     Department of Health funding, has been extended for
  25     a further one year pending discussions with the new

   1     body, the National Institute of clinical excellence, and
   2     how it might interrelate with that new special
   3     authority, NICE.
   4   Q. So the mechanism set up in 1996 was SERNIP?
   5   A. Yes.
   6   Q. Prior to SERNIP, would it be the case that the
   7     identification of a new technique which raised ethical
   8     issues or issues of training would be reliant upon the
   9     surgeons concerned and that they might, if they needed
  10     advice, be reliant on local ethics committees or
  11     research committees to discuss the problems raised by
  12     new techniques?
  13   A. You would be right in that, yes.
  14   Q. If one takes the second aspect of this issue, the first
  15     being how to identify the procedure, the second being,
  16     how do you train people to carry it out, the proposal
  17     that is set out there was that once a new procedure had
  18     been identified, its initial use had to be controlled
  19     and limited to a number of specialised centres for
  20     clinical trial, and that it would be tested during that
  21     trial, and that when its value was proven, all
  22     consultants who wished to use it would be required, as
  23     part of their CME certification, to show in evidence the
  24     form of certification of learning via those prescribed
  25     routes and by working with surgeons in the trial centres

   1     already skilled in the technique.
   2        Was that a mechanism or suggestion that has been
   3     pursued or developed in the years since that paper was
   4     published?
   5   A. The certification aspect of it has not happened,
   6     although I think it will happen as time progresses.
   7     There is strong evidence that surgeons now do go on
   8     prescribed courses to learn new techniques; many such
   9     courses of which are organised and run by my College,
  10     and there is also some evidence that they might also, or
  11     alternatively, go to work with surgeons in trial centres
  12     and such like. But what has not happened since that was
  13     written was that formal certification has taken place as
  14     part of CME certification.
  15        Evidence that they have attended courses, of
  16     course, can be provided, a piece of paper to say they
  17     have attended a course, but that is not quite as was
  18     meant, I think, in that paragraph that we have on the
  19     screen at the present time.
  20   Q. We can look at it in a little bit more detail, perhaps,
  21     through a paper that was written by Mr Dussek for the
  22     General Medical Council. It is dated 13th September
  23     1998. It is to be found at SCS 3/2.
  24        We can see from the start of the paper that it
  25     is a discussion document that in fact arose out of the

   1     GMC proceedings into the cardiac surgery at Bristol. It
   2     goes then to discuss the learning curve in the context
   3     of that.
   4        If we scroll down the page, we see first that
   5     Mr Dussek has set out the role of SERNIP, and has spoken
   6     of its efficacy in dealing with the problem of
   7     recognising new procedures.
   8        He goes on to say that unfortunately, admirable as
   9     the system is, it does not deal with the actual problem
  10     of a surgeon learning a new operative technique.
  11        He then goes on to discuss the learning curve or
  12     the phrase that is commonly used, and defines it as
  13     meaning that there might be an expected and acceptable
  14     excess of patients who will die or be harmed in the
  15     early experience of a learner, but who would have fared
  16     better if they were operated on by a surgeon who is on
  17     the plateau of experience.
  18        He comments that this is no longer a palatable
  19     concept.
  20        Can I ask you, was it ever a palatable concept?
  21   A. It was a term that was widely used and, sadly, is still
  22     used to some extent, although my College Council has
  23     agreed in debate, in discussion formally, that the term
  24     should be expunged from medical literature, and
  25     certainly I think that editors of journals will no

   1     longer accept that term in surgical articles.
   2        Be that as it may, it was a term that was very
   3     widely used when learning any new technique, and has
   4     been used ever since I was a medical student.
   5        I think the phrasing that is used there is
   6     somewhat dramatic in the sense of dying or harming
   7     patients, because I do not think that the learning
   8     curve, as it was usually used, referred to patients
   9     dying as a consequence of lack of experience, or being
  10     harmed by lack of experience, although in the field of
  11     cardiac surgery, and specifically in the field of
  12     paediatric cardiac surgery, that might have been the
  13     consequence of this inexperience of surgeons learning
  14     a technique on a patient, rather than by learning on
  15     a simulator or learning on animals, or going to learn at
  16     the feet of and together with some surgeon experienced
  17     in the technique -- "mentoring", as it is now called.
  18   Q. Are the possibly dramatic consequences of a learning
  19     curve on the part of a surgeon and problems related to
  20     that limited to the field of paediatric cardiac
  21     surgery? What about the experience of the profession in
  22     the introduction of minimally invasive surgery?
  23   A. The answer is, it is not limited to paediatric cardiac
  24     surgery, or to minimal invasive surgery; it was a term
  25     that was used across the entire spectrum of surgery,

   1     whatever specialty within surgery one is talking about.
   2        In the case of minimal access surgery, to which
   3     you refer, there were a large number of surgeons who,
   4     because they were experienced in carrying out
   5     gallbladder operations by conventional approaches,
   6     thought that they would be able to do it equally
   7     competently using the new minimal access technique. In
   8     the event, that was found not to be the case and quite
   9     a large number of complications ensued as a consequence
  10     of poor performance using this new technique.
  11        Having said that, there were an awful lot of
  12     surgeons who did not just jump at it like that and did
  13     go on courses, which were small in number but
  14     nevertheless available, or alternatively, go to other
  15     countries to learn the technique on anaesthetised
  16     laboratory animals, which of course is not permitted in
  17     the United Kingdom under current Home Office
  18     regulations.
  19   Q. The area I wanted to turn to was in fact the practice of
  20     the profession before this debate perhaps came out
  21     rather more into the open in recent years to try and
  22     have the benefit of your evidence upon what the
  23     acceptable practices or accepted practices for a surgeon
  24     would have been during the period of our terms of
  25     reference, when confronted with new procedures.

   1        It may be that one way of doing this would be to
   2     use Mr Dussek's paper as a reference tool, because if we
   3     turn over to page 3, he has very helpfully set out
   4     different categories of cases, problems that are raised
   5     by this field.
   6        I would like to have your comments, if you could
   7     help us, on not what is the accepted answer now, but how
   8     it would have been understood across the period with
   9     which we are concerned.
  10   A. I see there is an (a), (b) and possibly a (c). Before
  11     commenting on that, may I come back to my answer to you
  12     on an earlier question, I think before lunch, when
  13     I said that there was a moral responsibility among
  14     surgeons to practice at an appropriately high level.
  15        I think I would say again, that when new
  16     procedures were introduced or new techniques, new
  17     operations were introduced, there was a moral obligation
  18     on all surgeons of whatever grade, whatever seniority,
  19     to ensure that when they carried out those procedures,
  20     perhaps for the first time, they did so in a manner that
  21     would not in fact harm their patients so that they could
  22     say confidently that they were practising to an
  23     appropriate standard.
  24        I do genuinely believe that the majority of
  25     surgeons in the country would have had an exercise of

   1     that moral responsibility, but sadly, I think events
   2     have shown that that has not always been the case.
   3        I am thinking of the variation in human behaviour
   4     and human attitudes, I suppose that is not particularly
   5     surprising.
   6   Q. If one might start with the proposition that no surgeon
   7     would have wanted to harm his or her patient before
   8     embarking upon a new surgical procedure, that might well
   9     be something that would find widespread agreement
  10     amongst all. The issue might perhaps be more, what
  11     would be the expectations as to the practical steps that
  12     had to be taken before a person could be confident or
  13     reasonably confident that actually they would not be
  14     harming their patient if they embarked on something
  15     relatively new?
  16   A. There was nothing laid down about this. It was not
  17     formalised. It was up to an individual surgeon to take
  18     what steps they considered necessary to enable them to
  19     carry out that operation with a clear conscience.
  20   Q. So perhaps there might be a range of steps available to
  21     them. The obvious one would be to review the literature
  22     to make sure they were familiar at least in theory with
  23     the steps that needed to be taken in performing this new
  24     technique. That presumably is something that everybody
  25     would have been aiming to do during the period with

   1     which we are concerned?
   2   A. Yes, well, without either reading the literature,
   3     reading the technique in an article -- not a textbook,
   4     because if it was new it would not have got into
   5     a textbook, it would still be in an article in
   6     a journal -- or seeing a video, and videos were widely
   7     used at this time, or having seen the operation in
   8     somebody else's operating theatre when visiting another
   9     surgeon, I do not think any surgeon would embark on
  10     a new operation without one or other of those steps
  11     being taken before they put, as we say in the trade,
  12     knife to skin.
  13   Q. If the first level would be reviewing the literature,
  14     the second might be viewing a video; the third step that
  15     one might perhaps take would be to visit another centre
  16     and watch a colleague perform the procedure.
  17        How common would that have been as a method of
  18     informing oneself across the --
  19   A. I think it would have been less common than reading and
  20     watching videos, but I cannot quantify it. Certainly
  21     when minimal access surgery for gallbladders came into
  22     this country, those centres that set up training units
  23     and invited consultants and others to go and take part
  24     in their training programme had largely been to other
  25     countries, notably the United States, to a lesser extent

   1     France, where they learned the technique themselves.
   2     But you will appreciate that somebody had to do the
   3     operation for the first time ever on a human, having
   4     done it initially in laboratory animals, I might say,
   5     but with a new operation, somebody has to do that
   6     operation for the very first time in a human being. One
   7     hopes that the surgeon who undertakes that
   8     responsibility will have convinced themselves to the
   9     very best of their ability that they are competent to
  10     undertake that new procedure.
  11   Q. What about what might be called the fourth level, of
  12     satisfying oneself that one can carry this out: that if
  13     you are talking not about new procedures in the sense
  14     that they have never been performed before, but new
  15     procedures which are well-established elsewhere but not
  16     in the surgeon's own home hospital, as it were, how
  17     common would it be to go off and to perform the
  18     operation under the supervision of a colleague at
  19     another hospital where that procedure was
  20     well-established?
  21   A. It would not be common. That would be the least
  22     common method of ensuring to the best of one's ability
  23     that one was competent to carry out a procedure.
  24   Q. Does that answer relate to the present tense or to the
  25     period of our terms of reference?

   1   A. Both.
   2   Q. Would it have been a practice that was adopted at all
   3     during the period of our terms of reference?
   4   A. I cannot speak for cardiac surgeons because I have no
   5     personal experience in that field at all. It certainly
   6     was the case in the field of surgery in which
   7     I practised, although only to a limited extent, as
   8     I have said earlier.
   9   Q. If we then go on to this topic in the latest document,
  10     the RCSE 1/2, this is the College's response to the
  11     General Medical Council's determination. If we turn,
  12     please, to page 6 of that document, we can see what one
  13     might call "current thinking" towards the bottom of that
  14     page, please, where the College says in terms there
  15     should be no learning curve as far as patient safety is
  16     concerned. That, I think, is something you referred to
  17     earlier. You are nodding?
  18   A. Absolutely. That enshrines my own belief and the belief
  19     of my College.
  20   Q. It then goes on to say:
  21        "Colleges and specialist associations must work
  22     together to ensure that adequate training facilities are
  23     provided and to develop a system of professional
  24     mentors."
  25        If one looks back at paragraph 4 of this document,

   1     the reference to "mentors" appears there as well,
   2     because it says that "in the case of new and complex
   3     procedures, however, all surgeons wishing to learn must
   4     do so by assisting a competent practitioner until
   5     trusted by that mentor to operate independently."
   6        There is a new element in that, is there not?
   7     There is an obligation on the mentor for the first time?
   8   A. Yes.
   9   Q. Would that have been something understood by colleagues
  10     who were visited by someone wanting to learn about a new
  11     procedure prior to this document being produced?
  12   A. No.
  13   Q. So there is a development on the one hand in that
  14     document; on the other, it could be suggested that the
  15     system that is outlined here is less formal than the
  16     certification procedure that was envisaged by the
  17     document produced in 1994 that we started off by looking
  18     at?
  19   A. I think that is a fair point that you raise. The
  20     certification aspect I think is now, currently when this
  21     document was written. It is tied in with another aspect
  22     of this document, which is not on the screen at the
  23     moment and that relates to a proposed regular
  24     revalidation of professional practice to ensure that
  25     a practitioner is competent to continue being on the

   1     specialist register -- I am sorry, I did not want to
   2     introduce a new concept, but when this document was
   3     written by the College, it was envisaged that to remain
   4     on the specialist register as a surgeon one should be
   5     periodically revalidated or reassessed, and that that
   6     certification aspect that you mention would be tied in
   7     with that process.
   8   Q. So that issue is still under development, then, with the
   9     validation procedures?
  10   A. Very much so. I sit regularly, like every two weeks at
  11     the moment, on yet another group of people discussing
  12     these very matters and how these matters might be
  13     introduced within the very near future.
  14   Q. If I can just turn then to another aspect of this
  15     particular document, the response to the Bristol case at
  16     page 9 deals with the subject of how doctors explain
  17     risk to patients. It sets out the relationship between
  18     the consultant and the patient, the fact that areas of
  19     uncertainty and significant risk must be explored, the
  20     use of information leaflets and tapes, and then, at the
  21     bottom of that it says:
  22        "The colleges and specialist associations have an
  23     important role in the production of suitable information
  24     on a national basis but the surgeon must know and
  25     divulge local and personal figures ..." for the success

   1     or otherwise of an operative procedure, presumably.
   2        That is clear guidance from the College published
   3     in 1998. What would have been the standard in this area
   4     throughout the period of our terms of reference?
   5   A. I do not think it would be so explicitly stated as it is
   6     stated here for surgery in general. I cannot speak for
   7     particular branches of surgery and specifically for
   8     cardiac surgery because I do not know, but it would
   9     certainly have not been in any way firm College
  10     guidelines that on a national basis surgeons should
  11     divulge local and personal figures relating to outcomes
  12     such as has been recommended in this document.
  13   Q. Our understanding is certainly that there was no
  14     guidance to that effect because we are looking at a 1998
  15     document that I think is clearer than any other on that
  16     subject, but are you able to help us on the practice
  17     that would nevertheless have been adopted at a local
  18     level?
  19   A. I think it would have been uncommon, unless the patient
  20     had asked for that information. I imagine that that
  21     might differ from specialty to specialty within surgery
  22     because my understanding is that in the field of cardiac
  23     surgery, very high risk surgery, this information was
  24     not infrequently asked by relatives or by patients of
  25     the surgeon in question, whereas in other branches of

   1     surgery, it would have been extremely uncommon to have
   2     been asked that question.
   3        Certainly, from personal experience, not as
   4     a cardiac surgeon, I think I would have been asked
   5     specific questions regarding risks in general and
   6     certainly the risks in my own hands exceedingly --
   7     exceedingly -- infrequently over my entire professional
   8     practice.
   9   Q. The Inquiry will, of course, hear from parents and also
  10     from the doctors concerned as to what their practice
  11     was, but it might be suggested that it would be unusual
  12     for a patient to be able to have the knowledge, as it
  13     were, to ask not merely about what the outcome or likely
  14     outcome was in broad terms, but to be able, to make
  15     a distinction to go behind a 30 per cent risk of
  16     mortality, to ask such further questions as,  "Well, is
  17     that a national figure, is that a local figure, is that
  18     your personal figure?"
  19        That would accord with your experience, that
  20     patients did not really do that?
  21   A. Absolutely. I think it would have been most unusual for
  22     any patient to do that, and I would imagine, but others
  23     will be able to verify or refute my belief, that that
  24     would have been unusual in cardiac surgery, and
  25     specifically in paediatric cardiac surgery.

   1   Q. So this is an area where practice must have changed very
   2     recently and very rapidly?
   3   A. Well, I think that it does not happen now. I do not
   4     think patients by and large ask that information, other
   5     than, perhaps, in the field of cardiac surgery, largely,
   6     I suspect, as a result of the publicity that the
   7     circumstances in Bristol obtained.
   8   Q. What is being suggested in that guidance is that it is
   9     not merely surely a matter for the patient to ask, but
  10     for the doctor to volunteer this information?
  11   A. That is what is stated, correct.
  12   Q. But so far, does it follow from your earlier answer that
  13     that is not necessarily the practice, or is not common
  14     practice on the ground?
  15   A. I think that is probably not common practice, and as
  16     I have -- I think I have not said specifically, but if
  17     I have, I am sorry to repeat it; if I have not, perhaps
  18     I could say that any College guideline that comes out,
  19     such as the one you have on the screen at the present
  20     moment, is recommendation by the College to its fellows
  21     and others, but it is not mandatory upon our fellows and
  22     others to follow those guidelines or those
  23     recommendations.
  24   Q. No, we understand from your evidence that the College
  25     may set standards, but it has very limited powers,

   1     indeed, in terms of enforcement?
   2   A. Sadly, that is true.
   3   Q. If I could go on, then, more generally to the question
   4     of maintaining standards, because if we go back to your
   5     statement -- really this follows on from the observation
   6     I have just made -- at page 3, at the bottom of that
   7     page you set out the College's powers of disciplinary
   8     action against any members and you point out that the
   9     College may remove an individual's rights and privileges
  10     of Fellow after the GMC has taken action, but that it
  11     cannot of itself initiate disciplinary action against
  12     individuals in relation to their standards of
  13     professional practice.
  14        It does, as we know, and have heard throughout the
  15     morning, have a role in setting standards, both
  16     generally by way of guidelines and also by the training
  17     recognition work that it does.
  18        Are there any other mechanisms that you would like
  19     to emphasise in its role, in carrying out its function
  20     of maintaining standards?
  21   A. Had you anything in mind in asking that question? No,
  22     I think we have tried to explain as best we can what we
  23     can do, what we cannot do; what we would wish to do is
  24     something perhaps for the future.
  25   Q. I am grateful, I did not want to be less than thorough,

   1     but I think that it must be, then, that the Royal
   2     College would have at its disposal only a certain number
   3     of mechanisms for hearing of problems, if there were
   4     problems of performance by an individual surgeon, say,
   5     that there would be limited means of hearing of those
   6     problems. The first would obviously be the hospital
   7     accreditation visits, the training visits that we
   8     referred to?
   9   A. Yes.
  10   Q. But I think it follows from our discussion this morning
  11     that those may have only a limited efficacy in drawing
  12     attention to problems that existed at local level?
  13   A. We have increasingly -- I referred to this earlier in
  14     a reply -- had individual hospitals come to the College
  15     stating that there is a belief locally that an
  16     individual surgeon might be performing to a less than
  17     satisfactory standard.
  18        That might come to us through the Medical Director
  19     or it might come to us from a colleague, and recently,
  20     in the fairly recent past, it may come to us through the
  21     Chief Executive, through management.
  22        If that is the case, the College is now, and has
  23     always been, willing to help out when it can by asking,
  24     usually a pair of respected senior surgeons in the
  25     specialty concerned, to visit the hospital in question

   1     on an informal or formal basis, depending on the request
   2     of the hospital, to enquire impartially an external
   3     assessment of the perceived problem and to advise the
   4     Medical Director or the Chief Executive accordingly.
   5        I myself have taken part in such visits 5, 6 years
   6     ago, before Bristol came on the scene publicly, and it
   7     continues today, and I have to say that in the past 12
   8     months, we have probably had rather more requests during
   9     that 12 months than we have had in any previous 12
  10     months.
  11   Q. So if the College is informed by someone, whether
  12     informally or more formally, that there is a problem, it
  13     would be willing to act, if invited, by instituting
  14     a review?
  15   A. Correct.
  16   Q. By independent practitioners. That is a reactive
  17     response which perhaps is dependent upon an invitation
  18     to contact, discuss the matter with the institution
  19     concerned?
  20   A. Correct.
  21   Q. What would happen in the slightly different situation
  22     of the College hearing, as it were, gossip or rumours,
  23     the "word on the street" being that there was a problem
  24     because of its network contacts with practitioners in
  25     the area? Would it feel under any obligation to

   1     investigate rumours of that sort?
   2   A. Currently, or in the past?
   3   Q. Let us start with currently, if I may.
   4   A. Yes, it would have an obligation to investigate
   5     further.
   6   Q. If one takes it back into the past, into the terms of
   7     reference again?
   8   A. I think it would have been less likely to enquire on
   9     evidence of unfounded rumour and gossip, although
  10     I cannot speak with certainty on that because I would
  11     not have been party to any such gossip and rumour
  12     reaching the College, because it would tend to come to
  13     the President or the Vice President at a very senior
  14     level, and until I had been involved at that level in
  15     College affairs, I would not be aware if any such
  16     information had come to the knowledge of the College.
  17        I think in the past the College would have been
  18     wary, chary, let us put it, of doing anything in the
  19     wake of "unfounded gossip", as you put it.
  20   Q. At what point does an approach by an organisation say,
  21     when they think they have a problem, become sufficiently
  22     distinct from gossip? What is the difference between
  23     those two situations and perhaps the middle situation
  24     where perhaps an individual clinician has concerns but
  25     does not have black and white evidence to prove his or

   1     her position one way or the other but talks to someone
   2     within the Royal College about it?
   3   A. If a clinician approaches the College and says that
   4     they are concerned about a colleague's performance or
   5     some aspect of practice at their particular institution,
   6     and asks for the College to be involved, the College
   7     would be willing to be involved by writing to the
   8     Medical Director of the Trust and saying "It has come to
   9     our notice that there may be a problem in [a particular
  10     area]. We draw your attention to this and we would
  11     offer to put in independent assessors to come and have
  12     a look at the matter if that is your wish. We would
  13     like to hear from you as to your observations on the
  14     matter."
  15        I think currently the Medical Directors would
  16     almost inevitably take up the offer of the College's
  17     help in these matters. Previously, I think they may
  18     have wished to keep it local or they may have asked the
  19     College in, varying, depending on the particular
  20     magnitude of the problem and the particular problem and
  21     whether they perceived it as a problem.
  22   Q. Again, if one takes that answer back to the period 1984
  23     to 1995, would the College's attitude have been similar
  24     at an earlier stage?
  25   A. I cannot tell you formally what the College's attitude

   1     was in 1985, because I was not involved with College
   2     affairs at that time. These matters were very
   3     sensitive, as I am sure you will appreciate, and there
   4     is a fair degree of confidentiality necessary when these
   5     unsubstantiated allegations arise. The College has to
   6     act discreetly in case it all comes to nothing at all,
   7     as it certainly has done on some of the matters where
   8     the College has been asked to go and assess.
   9   Q. If I could take the example of a surgical unit in which
  10     one person, say, a clinician but not the leading
  11     clinician, takes the view that there are problems with
  12     outcomes but does not have final, as it were, conclusive
  13     proof that anyone could look at and say, "Yes, you must
  14     be absolutely right", could I ask you for your views on
  15     the role or responsibilities firstly of the management
  16     of the hospital in that situation, firstly if we take
  17     the situation prior to the creation of Trusts so that
  18     the management would in fact be the District Health
  19     Authority?
  20   A. I think it would have been usually the case at that time
  21     that management would not have been heavily involved in
  22     these affairs, but it would vary, I am sure, from Trust
  23     to Trust because the relationship between clinicians and
  24     management varied enormously from Health Authority to
  25     Health Authority and then Trust to Trust.

   1        I have had the great privilege of working in
   2     a hospital where management and clinicians had a very
   3     close and very easy and harmonious working relationship,
   4     even with changes of management and changes of
   5     clinician, but I know from discussions with colleagues
   6     that has not been the case throughout the country.
   7   Q. Would the entitlement of management to be concerned with
   8     that issue have been recognised by clinicians at that
   9     time?
  10   A. I think it would vary from clinician to clinician.
  11     There would certainly have been some that would have
  12     thought it entirely appropriate that management should
  13     be involved, but equally, I suspect there were others
  14     that were less confident of that. Indeed, it is quite
  15     widely known that relationships between some managers
  16     and some clinicians were extremely bad in the past.
  17   Q. If we go back to the evidence, as an example, of
  18     Dr Roylance to the Inquiry -- I am looking at, for the
  19     record, Day 24/14, where Dr Roylance was asked:
  20        "Can I examine the values as opposed to the
  21     objectives of the management of this hospital? Am
  22     I right in thinking that essentially your concept of the
  23     organisation of the Trust and of the Health Authority
  24     before it was that it should be medically led?"
  25        He answered:

   1        "No, that was my observation, not my concept.
   2     Health care is led by consultants. That was not
   3     something I imposed; it was not my concept, it was my
   4     recognition of reality ...."
   5        The question was put to him:
   6        "In effect, once appointed, was it part of the
   7     consequence of clinical freedom that they, i.e.
   8     consultants, were self-teaching and self-correcting?"
   9        The answer was "Yes".
  10        "Did you take the view, therefore, that it was not
  11     for managers to interfere?"
  12        He answered:
  13        "I recognise that it was impossible for managers
  14     to interfere."
  15        If one goes on to page 15, line 17, he was asked:
  16        "So your view was that it was for doctors to
  17     identify failings in doctors?"
  18        He answered:
  19        "You keep asking if it was my view. It was the
  20     view. Nobody else had a different view. I am really
  21     anxious that I should not mislead anybody that I had in
  22     some way introduced a different concept into the health
  23     service than that which existed throughout the Health
  24     Service."
  25        Could I ask you for your general comments upon

   1     that evidence as to whether or not that concept of the
   2     limitations of the functions of management within the
   3     Health Service was generally shared throughout the time
   4     by other practitioners?
   5   A. I go back to what I said earlier. I am sure that
   6     Dr Roylance, in his response, was stating exactly what
   7     he believed to be the case. Certainly it was the case
   8     in his own hospital and it was clearly what he believed
   9     to be the case across the entire country.
  10        I have to be honest, I am less convinced that it
  11     was as rigidly so across the country as Dr Roylance
  12     would suggest in his evidence, whilst not in any way
  13     disputing that that was his personal experience.
  14        I just go back to what I said earlier: I think the
  15     relationship between management and clinicians did vary
  16     from Trust to Trust, District Health Authority to
  17     District Health Authority, and I would not be quite as
  18     certain in my own mind that that was universally the
  19     case as Dr Roylance appears to be, but I have no hard
  20     evidence other than my own experience when I give that
  21     answer.
  22   Q. What would you conceptually regard as being the role of
  23     management in such a situation as I started off by
  24     positing, when there are some concerns being expressed
  25     about the performance or outcomes of a particular

   1     service within a hospital?
   2   A. Conceptually, I think if management was aware of that it
   3     would be up to management to discuss that with the
   4     clinicians concerned to try and resolve the matter,
   5     quite clearly.
   6   Q. Is that something that any other body within the
   7     structure of the NHS would also have any role? What
   8     about the role of, for instance, the district health
   9     administration prior to the creation of Trusts?
  10   A. No, I repeat what I say. If the district administrator
  11     became aware of an alleged clinical problem reflecting
  12     on the standard of patient care, then I think it would
  13     behove that district administrator to discuss that with
  14     the appropriate clinician who would in the first
  15     instance, I imagine, have been Chairman of the Medical
  16     Staff Committee to discuss how the matter might be taken
  17     further.
  18        I would not have envisaged it the case that the
  19     district administrator would himself or herself
  20     intercede directly, but through the medium of the
  21     appropriate medical representatives.
  22        If I can draw on my own experience, if I may,
  23     I was Chairman of the medical staff committee of my own
  24     hospital in the early 1980s, before the time of this
  25     Inquiry, and I had a very close and easy working

   1     relationship with the district administrator in my
   2     hospital, and had such problems arisen, I am quite sure
   3     they would have been discussed between us, and I would
   4     have taken it on then as a doctor with the clinicians
   5     involved, not the administrator doing that. But they
   6     would have been able to talk to me.
   7   Q. What would you say to the position of the Regional
   8     Health Authority in this structure? Does it have
   9     a similar duty to investigate?
  10   A. I come back to what I said this morning: I do not think
  11     the region would be involved unless there was a health
  12     issue. My recollection is that if there was a perceived
  13     health problem with a consultant, then the regional
  14     administrator or the regional -- not the regional
  15     administrator, I withdraw that. The Regional Medical
  16     Officer, as I recollect, would be involved in
  17     instigating the "three wise men" procedure and the three
  18     wise men, I recollect, reported to the Regional Medical
  19     Officer.
  20   Q. If we go back to the government's envisaged strategy for
  21     medical audit -- I am looking again at HOME 3/127.
  22     I think we need to turn forward to 129, there is
  23     a structure set out. Can we go to page 130, where there
  24     we see in general that there has to be a local medical
  25     audit advisory committee chaired by a senior clinician

   1     and that I think it is right in saying that in fact the
   2     regional office, the Regional Health Authority, in most
   3     structures ended up with responsibility for medical
   4     audit and with medical audit committees reporting to
   5     a regional Medical Audit Committee.
   6        If that is right, would that not give the region
   7     some role in overseeing the structure or the outcome of
   8     procedures?
   9   A. If that is the case, then the logic of what you say is
  10     irrefutable. I have to be honest: I was not aware that
  11     that was the case. Certainly, my recollection of this
  12     time and my own personal experience -- nothing to do
  13     with the College -- was that the region was not involved
  14     in the medical audit process and the Medical Audit
  15     Committee of the hospital in which I worked. That is my
  16     recollection of my own experience.
  17        I have not, I am afraid, had the opportunity of
  18     systematically checking this out. I would accept
  19     correction if I am wrong on this.
  20   Q. No, the fault is mine, Mr Jackson, because I do not have
  21     the reference to hand, but in any event, it may be that
  22     if the region had any role in medical audit, that might
  23     give it a function; otherwise it was not your experience
  24     that it was so involved?
  25   A. That is correct.

   1   Q. If one takes the question of other bodies -- I am
   2     thinking still of the district authority and the
   3     region's involvement in the maintenance of standards
   4     here -- what information would such as it were
   5     "outsiders" have had throughout the period of our terms
   6     of reference on these issues?
   7   A. By "outsiders" you mean the region?
   8   Q. I mean the region and the district health authorities;
   9     persons or bodies outside the hospital, in other words.
  10   A. I am not sure that I can answer that question
  11     authoritatively. I imagine the answer would be that
  12     they would have very little, if any, knowledge of this,
  13     but I may be incorrect in that. Certainly, I had no
  14     knowledge that they would have been involved, but
  15     I would need to check on that. I just do not know with
  16     certainty the answer to your question except from my own
  17     experience, which was that the district and the region
  18     were not involved in these matters.
  19   Q. I think in fact the question I am putting to you merely
  20     follows from the subjects we have been discussing
  21     earlier, which is that there was very little information
  22     available about outcomes of procedure generally within
  23     our period and that information that was generated by
  24     clinical or medical audit was not information that would
  25     necessarily have passed beyond the clinical group that

   1     was generating that information. Is that a fair summary
   2     of the discussion we have been having earlier?
   3   A. That is exactly a fair discussion, but the point I was
   4     making was that had medical audit exposed a particular
   5     problem within a hospital working within the Trust or
   6     District Health Authority, I am not convinced that
   7     information would have been relayed necessarily to the
   8     Health Authority or to the Regional Health Authority.
   9   Q. Thank you. Just generally looking at the whole area of
  10     how a problem about clinical performance might in
  11     reality be tackled if it had become manifest, at least
  12     to one person within a clinical group, how would you
  13     suggest that the various factors that we have been
  14     discussing are going to be reconciled in reality? I am
  15     thinking here of, firstly, the independent consultant
  16     status of the consultant which may make it difficult for
  17     local management to feel that it has a role in
  18     monitoring clinical standards of outcomes; secondly, the
  19     fact that the GMC and the Royal Colleges will tend to
  20     react only as and when concerns have been expressed to
  21     them, that is, that they are primarily reactive rather
  22     than proactive; and thirdly, the fact that very little
  23     information about problems on clinical outcomes and
  24     standards might be available to bodies outside
  25     a hospital, whether one is thinking about the District

   1     Health Authority, the Regional Health Authority or
   2     purchasers in a generalised sense?
   3   A. Because what you say is absolutely true, in my opinion,
   4     it is the reason why I have been public in my statements
   5     to say that the profession has to put into place
   6     measures to ensure that what you say is no longer the
   7     case.
   8        I believe that this all happened through
   9     a combined process of the clinical governance measures
  10     that are being adopted as we speak by every Trust in the
  11     country, and are being refined and developed, and the
  12     revalidation of consultants and others that will be
  13     introduced by the General Medical Council within the
  14     next two years, of which the Colleges and the specialist
  15     associations will be, in my view -- have to be in my
  16     view -- an integral part. I firmly believe that when
  17     these measures have been fully implemented, as they
  18     will, within the next two years in round figures, the
  19     problems that you allude to as not having been addressed
  20     will have been addressed by the profession.
  21   Q. Thank you, Mr Jackson. That may be a convenient moment
  22     to stop. Before we do, could we just clarify the one
  23     point that I did not have the reference for, which was
  24     the role of the region in audit? If we can turn to
  25     page 133 of this document and to paragraph 4.4 in

   1     particular, the role that I was attempting to summarise
   2     is there set out.
   3   A. The only answer I can give you to that is that I am not
   4     familiar with this document which is on the screen.
   5     I clearly should be. I apologise for that. I think you
   6     said this was 1989? My professional experience in 1989
   7     was that in my particular hospital, so far as I was
   8     aware, the region were not at any time involved. That
   9     may be something that should have happened but did not
  10     happen; it may be that it was happening without my
  11     knowledge.
  12   Q. Thank you. Mr Jackson, I have come to the end of the
  13     questions I wish to ask you. Before I invite the Panel
  14     to ask any further questions, could I ask whether there
  15     is anything further that you would like to draw to their
  16     attention, or that of the wider audience, that you feel
  17     has not been adequately covered this morning and this
  18     afternoon in questions directed at you?
  19   A. The only thing I would wish to say there is to perhaps
  20     re-emphasise my answer to your very last question before
  21     we came on to the supplementary, and that is to say that
  22     my College is committed to ensuring in the future that
  23     mechanisms are established whereby maintenance of
  24     standards can be seen to be maintained, and will be
  25     maintained in the future -- my College is totally and

   1     absolutely committed to that -- such that the events
   2     leading to this Inquiry being set up would not be
   3     repeated in any branch of surgery in the future.
   4   MISS GREY: Thank you, Mr Jackson.
   5   THE CHAIRMAN: Mr Jackson, there are some questions from
   6     colleagues on the Panel. Mrs Maclean?
   7             Examined by THE PANEL:
   8   MRS MACLEAN: Thank you. Mr Jackson, you were helping us
   9     earlier by talking about the way in which the College
  10     might become aware of concerns about clinical
  11     performance in a particular service or by a particular
  12     clinician.
  13        You mentioned the possibility that a clinician
  14     might directly approach the College with such
  15     a concern.
  16        Would you envisage such an avenue of communication
  17     as pertaining only to members of the same clinical
  18     specialty, or might such a communication come across, as
  19     it were, disciplinary boundaries?
  20   A. My experience to date, and I believe the experience of
  21     my predecessors as Presidents of the College, would be
  22     that it has come from surgeons in whatever discipline
  23     within surgery. But I think you were referring to
  24     whether it might come from, say, an anaesthetist or
  25     a nurse.

   1        I would like to feel in the future that that
   2     avenue would be open to an anaesthetist or a nurse, or
   3     any other professional working within a hospital, and
   4     that the College could act appropriately given that
   5     information from a source within the hospital.
   6        There is nothing laid down to prevent that
   7     happening now, but it just does not seem to happen.
   8        I would have said, I think it came up in reply to
   9     one of Miss Grey's questions allied to this topic of
  10     teamworking, that it is absolutely true that some other
  11     members of the broader team have a very shrewd opinion
  12     as to the performance of a surgeon. It is widely said
  13     that if you want to know how good a surgeon actually is,
  14     ask his or her anaesthetist. That statement is
  15     something that has been extant for 25 years. Equally,
  16     the nursing staff have a very shrewd idea as to who gets
  17     very good results in terms of outcomes and those who
  18     sometimes patients have a little longer to get over
  19     certain procedures.
  20        But to the best of my knowledge, anaesthetists and
  21     nurses are not routinely asked about this. My
  22     perception, when revalidation comes about, is that there
  23     will be the opportunity for members of staff such as
  24     nurses and such as anaesthetists and others to have
  25     input into an individual consultant's revalidation, just

   1     as there might be the opportunity for patients, the lay
   2     public, to have an input into that revalidation
   3     exercise. This is something that the College is working
   4     on closely in conjunction with the other Medical Royal
   5     Colleges and the GMC at the present time.
   6   MRS MACLEAN: Thank you.
   7   THE CHAIRMAN: Mrs Howard?
   8   MRS HOWARD: Mr Jackson, you talked at some length about the
   9     involvement of management and managers in clinical
  10     concerns, and you gave what I think you called your
  11     "personal view" of the concept of the role of
  12     management.
  13        Does the College have a formal view or have they,
  14     in the past, issued guidance on the involvement of
  15     management in respect of clinical concerns?
  16   A. No. The College has not taken a formal view on this,
  17     either in the past or currently. Perhaps it is an area
  18     we should explore.
  19   MRS HOWARD: Thank you.
  20   THE CHAIRMAN: Professor Jarman?
  21   PROFESSOR JARMAN: We have heard about the limited ability
  22     of the Royal Colleges in terms of looking at quality of
  23     care, and I think we have heard that really it is mainly
  24     inspection of hospitals and posts to give approval for
  25     training where they have the most power to influence

   1     things.
   2   A. Yes.
   3   Q. Would you say that the inspections are mainly designed
   4     to make sure that trainees have adequate clinical
   5     experience and supervision, or would you say they were
   6     designed to examine the quality of the care in the hospital?
   7   A. The former.
   8   Q. I ask that question because we have had conflicting
   9     evidence, and Miss Grey referred to it earlier. For
  10     instance, Dr Roylance said -- I am quoting from his
  11     written statement -- that "the Royal Colleges had an
  12     overall responsibility for the maintenance of standards
  13     and that if concerns about such issues were made known
  14     to them, they would notify me that appropriate action
  15     was required."
  16        Does that fit in with your reply just now?
  17   A. Dr Roylance was Chief Executive.
  18   Q. He was, yes.
  19   A. The College would normally have contacted the Medical
  20     Director rather than the Chief Executive, depending on
  21     the source of the complaint, the allegation. This is in
  22     1995, we are talking about?
  23   Q. It is more or less the period we are covering in the
  24     Inquiry. What he basically says is that the Royal
  25     Colleges had an overall responsibility for the

   1     maintenance of standards. Would you agree with that?
   2   A. That was our declared position. The way we did that,
   3     other than through our training of trainees, is open to
   4     question, as has been shown by Miss Grey, because we had
   5     no statutory way in which we could maintain standards at
   6     consultant level at that time, or even now we have no
   7     statutory method of doing it, other than by removing
   8     trainer status. We have already explained that most
   9     consultants wish to retain that.
  10        We would hope that in the future that that deficit
  11     could be rectified. The way I see it being rectified is
  12     by the Colleges working with the specialist association
  13     in the revalidation process.
  14   Q. Thereby giving you statutory powers?
  15   A. Yes, I would wish very much indeed that the Medical
  16     Royal Colleges could be given statutory powers to
  17     maintain standards at consultant level, just as they now
  18     have statutory powers of maintaining standards for
  19     trainees in ensuring that any consultant appointed is
  20     appropriately qualified and trained and competent to
  21     carry out the responsibility of a consultant. That
  22     statutory responsibility has only been given to them in
  23     the last two years through the medium of the specialist
  24     training authority and the College's participation in
  25     the specialist training authority. I would like to see

   1     that extended to consultant level, and I think that that
   2     would strengthen medicine throughout this country
   3     enormously. And I hope very much it happens.
   4   Q. Thank you. On a different subject: in the papers that
   5     you sent us, RCSE 2/193, there is a letter from
   6     Sir Terence English to Norman Browse, who had just
   7     become President of your College, June 1992, that the
   8     College working party on neonatal and infant cardiac
   9     surgery had ignored the high mortality for open heart
  10     surgery at the Bristol unit.
  11        If you scroll down a bit on that page:
  12        "It is clear from a review of table 1 in the
  13     report that their mortality statistics both for infant
  14     age group and the older age group is worse than any
  15     other centre. David Hamilton agrees that sufficient
  16     attention was not paid to this by the Working Party."
  17        The data were a series of death rates by the
  18     various units. Do you think that the College really had
  19     the ability at that time to analyse that form of
  20     information in 1992? Would you have any idea?
  21   A. I have seen the report in question and read it when we
  22     were preparing the information that we furnished the
  23     Inquiry with. The tables need quite a lot of studying.
  24     They are not the clearest tables, in my view.
  25     Nevertheless, when one does look at them closely, there

   1     are numbers in there which differ from unit to unit
   2     carrying out paediatric cardiac surgery at that time,
   3     Bristol being one of them. So I think Sir Terence's
   4     statement there is probably a factually correct one.
   5   Q. Would the College have had this sort of statistical
   6     input to make sense of it?
   7   A. I doubt very much if there was any formal statistical
   8     input by the College at that time.
   9   Q. On to another subject completely. We have heard a lot
  10     about workload pressures on paediatric cardiac surgery,
  11     and at another document you gave us, RCSE 1/148, from
  12     the Senate of Surgery of Great Britain and Ireland,
  13     Provision of General Medical Services for Children, it
  14     says that there are currently 76 consultant paediatric
  15     cardiac surgeons in England and Wales against the
  16     recommended 99, or 169 for general paediatric cardiac
  17     surgery work to be done by a consultant paediatric
  18     surgeons.
  19        Do you think it is possible that this
  20     under-provision could affect the quality of care?
  21   A. I do not think quality of care and high throughput,
  22     which is required very often by Trusts, is compatible
  23     with insufficient staff to carry out the care required.
  24     I think there is an enormous shortage of consultants in
  25     all specialties in this country at the present time.

   1     Specifically within surgery, the College has been
   2     pushing and arguing with government and Trusts for more
   3     consultant surgeons in all disciplines within surgery
   4     for some considerable time now without very much
   5     response and it is a matter of enormous concern to my
   6     College and I know to other Medical Royal Colleges that
   7     there is insufficient consultant manpower to do the
   8     volume of service work and maintain the standards that
   9     we would all wish to see. I think it is a very worrying
  10     matter indeed, and I am delighted to be able to put that
  11     on record in this Inquiry.
  12   Q. The final point I wanted to raise was that in discussion
  13     with Miss Grey about the learning curves and so on, she
  14     quoted the evidence of RCSE 1/6 that "the process of
  15     supervised training described above should be regulated
  16     to ensure that no surgeon undertakes any procedure
  17     unless competent to do so".
  18        You mentioned that you were on a Working Party at
  19     the moment to do with certification processes and so
  20     on. I do not know whether you will be able to give us
  21     any more information. Is this the sort of idea whereby
  22     surgeons would be licensed to perform specific
  23     operations which would be monitored and they would be
  24     regularly relicensed or something like that?
  25   A. No. Procedural licensing is not under discussion at the

   1     present time.
   2   Q. It is not?
   3   A. No, it is not.
   4   THE CHAIRMAN: I have one question, Mr Jackson. In your
   5     reference to "minimal access surgery", as I recall you
   6     said that it was introduced in a somewhat uncontrolled
   7     fashion and that this caused let us say "problems".
   8        Talking about the period of time we are concerned
   9     with, and reflecting upon the culture which then and
  10     perhaps even now prevails, I wonder how one reconciles
  11     the proposition that something is introduced in an
  12     uncontrolled fashion with the counter proposition about
  13     clinical freedom, because to a degree it has been said
  14     that paediatric cardiac surgery was introduced at
  15     centres and units other than those designated by the
  16     Supra-regional Advisory Group, and there was an example,
  17     if you like, of an uncontrolled fashion, but it was put
  18     to us that that is what clinical freedom is about.
  19   A. I do not think that there should be clinical freedom to
  20     the extent that any practitioner can do whatever they
  21     wish in terms of procedures on another human without
  22     regard to the consequences of that action. So I think
  23     to that extent the term "clinical freedom" is perhaps
  24     a loose one. It is widely used, I agree, and the point
  25     you make is a fair one.

   1        I come back also to what I said earlier about
   2     a moral responsibility to one's patient. I do genuinely
   3     believe that those surgeons who had problems with their
   4     patients, having carried out minimal access surgery --
   5     I am thinking of gall bladder surgery particularly --
   6     were genuinely extraordinarily distressed and unhappy
   7     and full of remorse about the complications that ensued
   8     from their own carrying out of these procedures, because
   9     they had not realised at the time that they did them the
  10     complete change in technique that was required and the
  11     fact that hand and eye co-ordination in two dimension,
  12     looking at a television screen rather than looking into
  13     an open wound, was as difficult as it actually
  14     transpired that it was, for some individuals.
  15        Looking back on it, I think the profession learned
  16     an enormous amount from this particular episode, even to
  17     the extent, arguably -- I have to accept it is
  18     arguable -- that the long-term good might actually
  19     outweigh the short-term harm that was done during that
  20     very unfortunate period in the early 1990s when this was
  21     introduced in an uncontrolled fashion, because it did
  22     focus the mind, as I said to Miss Grey, in a major way
  23     on how new procedures should be introduced. I think, in
  24     fact I am confident, that a happening similar to the
  25     minimal access introduction will not happen again in the

   1     future as a consequence of the steps that have been put
   2     in place.
   3   Q. Miss Grey also rehearsed not only new procedures as such
   4     but any surgeon doing something which for him or herself
   5     was new, and you would go along with that also, the idea
   6     of some controlled phasing in as we saw from that
   7     document?
   8   A. Very much so. I support the substance of Mr Dussek's
   9     paper. I only saw it today for the first time, but on
  10     a quick glance I think I would support everything that
  11     he has written in that paper.
  12   Q. Do you think that you would be, by holding that view as
  13     regards clinical freedom, something of a radical or
  14     maverick to others?
  15   A. I am quite sure that there are fellows within my College
  16     who would challenge my view, but I see my position as
  17     President of the College to change theirs.
  18   THE CHAIRMAN: I am very grateful to you, Mr Jackson.
  19        I repeat what Miss Grey said to you: we are
  20     grateful to you for the evidence and for the material
  21     you have put in. If there are other matters which come
  22     to you which you think will be of help to us, and that
  23     includes material we have talked about today which you
  24     said you might be able to look for, we would be very
  25     grateful if you could. We will be here for a while and

   1     therefore would be happy to receive whatever else you
   2     may have for us.
   3        If I could impose on you for a couple more
   4     minutes, if you are able to sit there for just a second
   5     whilst Miss Grey tells me and those who are listening
   6     and watching elsewhere what we can expect over the next
   7     few days.
   8          TIMETABLE OUTLINED BY MISS GREY:
   9   MISS GREY: There are two procedural matters, Chairman. The
  10     first is that we, of course, adjourn today. We will not
  11     be sitting tomorrow but we will reconvene on Wednesday
  12     for a 12.30 start when we hope to hear from Dr Baird,
  13     who is the former Medical Director of the UBHT.
  14   THE CHAIRMAN: Forgive me, I thought it was 1 o'clock.
  15   MISS GREY: I am sorry, the timetable I was provided with
  16     said 12.30, but I am happy to accept that it is
  17     1 o'clock.
  18   THE CHAIRMAN: Can we say 1 o'clock, for the clarity for
  19     everyone.
  20   MISS GREY: Thank you. The second matter is that we, the
  21     Inquiry Counsel, have been requested by the legal team
  22     acting for the Executive of the Bristol Heart Children's
  23     Action Group to assist in broadcasting a message
  24     concerning meetings of members of the group with their
  25     legal team. We are told that the purpose of those

   1     meetings is to allow the legal team to bring up to date
   2     the members of the group with the progress that has been
   3     made by the Inquiry and the team's role -- their team's
   4     role -- in the Inquiry. The dates of the meetings are
   5     as follows: today, Monday 14th, in Bristol at 6.30 pm;
   6     Monday 28th June in Swansea; Wednesday 30th June in
   7     Tiverton; Monday 5th July in Gloucester; and Tuesday
   8     27th July in Truro.
   9        I make that announcement for the sake of the
  10     transcript, Chairman. The Inquiry counsel are happy to
  11     provide generalised assistance in letting the public
  12     know of any meetings which are relevant to participants
  13     in the Inquiry, and of course we are willing to do that
  14     in the future, to all groups who have a role and play
  15     a part in this Inquiry, in the hope that it will assist
  16     their co-ordination of contributions to the Inquiry.
  17   THE CHAIRMAN: I am grateful. Anyone who wants us, as it
  18     were, to help in making the Inquiry both as inclusive
  19     and as open as possible, we will through you be happy to
  20     do that. I am glad you are able to do that. Others may
  21     equally approach you on the matter.
  22        For today, therefore, thank you everyone. Thank
  23     you, Mr Jackson; thank you, Miss Grey. We will
  24     reconvene on Wednesday at what we have agreed to be the
  25     time, 1 o'clock.

   1   (3.50 pm)
   2     (Adjourned until 1.00 pm on Wednesday, 16th June 1999)
   3
   4
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   6                I N D E X
   7
   8
   9     MR BARRY JACKSON (SWORN):
  10        Examined by MISS GREY ....................... 1
  11        Examined by THE PANEL ....................... 137
  12
  13     TIMETABLE OUTLINED BY MISS GREY ................... 148
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Published by the Bristol Royal Infirmary Inquiry, July 2001
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