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

FULL TRANSCRIPT

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

   1     been and how it has come about that we might need,
   2     according to this Standards document, more consultants
   3     as a result of those two factors?
   4   A. Unit doctors or trainees, as they are now rightly
   5     referred to, in the past would work 100 or so hours
   6     a week, not all of it working, some of it sleeping.
   7     Nevertheless, they were available for that time. Not
   8     unreasonably, they wanted a family life of sorts, and
   9     there were also European directives on hours.
  10        The consequence is that junior doctors' hours,
  11     trainees' hours, have been cut from around 100 to around
  12     50; in other words, their hours have been cut in two.
  13        Calman training proposals have streamlined
  14     training from the sort of training I did, which took 10
  15     to 11/12 years, down to 5 or 6 years.
  16   Q. That is in order to reach c