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 Back to list of daily transcripts Hearing summary 30th 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, Welsh Office and professional organisations.   Professor George Alberti, President of the Royal College of Physicians, began by stating his aspirations for the outcome of the Inquiry. He hoped for recommendations to ensure that standards of quality and care in all parts of the country can be met. He also stressed the importance of adequate medical staffing for specialist units. He highlighted the Royal College’s explicit change in emphasis towards improving, rather than the setting of, standards. Professor Alberti told the Inquiry about the role of the Royal College in accrediting training posts and its responsibility for managing training programmes and outlined the process of Continuous Medical Education (CME) for clinical staff. He was asked about the Royal College’s reaction to expressions of concern about paediatric cardiac services in Bristol in 1987 and he replied that he would forward information to the Inquiry regarding any accreditation visits to Bristol. He said that at that time, there had been a severe manpower shortage in paediatric cardiology. He went on to tell the Inquiry about the development of audit.   Rita Le Var, Director of Educational Policy/Asst. Chief Executive, English National Board for Nursing Midwifery and Health Visiting (ENB), and Susan Jane Marr, Director for Adult and Children’s Nursing, ENB, completed the weeks’ oral hearings prior to the Easter break today. They outlined the role of the ENB and spoke about the history of nurse training, focussing on the training requirements of children’s nurses, Registered Sick Children’s Nurse (RSCN). They explained that most nurses wanting to care for children would first complete general training to registration level and then undertake post registration training in paediatric nursing. They confirmed that there had been, and still remains, a shortage of qualified children’s nurses and drew attention to a specific shortfall in paediatric intensive care nurses. They identified various reasons for this, not least limitations on promotion prospects. They went on to describe the purpose of the ENB in accrediting training sites and establishing new training programmes.   Chairman of the Inquiry, Professor Ian Kennedy, concluded the oral hearings today by thanking all witnesses to date for their evidence and by acknowledging the hard work, which has been going on behind the scenes, of the Inquiry staff. He said that the Inquiry had completed block one evidence and was ahead of schedule with block two. He went on to announce that the first batch of documents to be used in evidence over the coming weeks would be sent to legal representatives in CD form before Easter. The two CDs contain over 15,000 pages in searchable form and consists of documents from the United Bristol Healthcare NHS Trust, Welsh Office and Department of Health. The Inquiry will resume oral hearings on April 19th with more block two evidence from professional organisations.

FULL TRANSCRIPT

   1     Day 9, 30th March, 1999
   2   (9.30 am)
   3   THE CHAIRMAN: Mr Langstaff, good morning.
   4   MR LANGSTAFF: Good morning, Chairman. This morning we have
   5     the advantage of hearing from Professor Alberti of the
   6     Royal College of Physicians:
   7          PROFESSOR GEORGE ALBERTI (Sworn):
   8            Examined by MR LANGSTAFF:
   9   Q. Professor Alberti, your full name, please?
  10   A. Kirk George Matthew Myer Alberti.
  11   Q. Your professional address?
  12   A. Royal College of Physicians, 11 St Andrew's Place,
  13     Regents Park, London.
  14   Q. You are the President of the Royal College of
  15     Physicians?
  16   A. Yes, I am.
  17   Q. May we have on screen, please, witness 32/1. You should
  18     see in the screen to your right the first page of
  19     a statement which, if we go to page 14, it ends. I am
  20     not sure my copy is signed, but that is your statement?
  21   A. It is indeed.
  22   Q. I shall not take you through your statement in any
  23     particular detail. What I want to do is to concentrate
  24     on a number of aspects of it. I am aware, and I mention
  25     it so that others are aware, that you have a commitment

   1     which means you have to leave by 11 o'clock?
   2   A. Yes, thank you.
   3   Q. Can I begin, as it were, at the end? You, I think, as
   4     President of the Royal College of Physicians, have an
   5     ambition as to what might be the result in terms of the
   6     improvement in standards generally in the medical
   7     profession of this Inquiry?
   8   A. That is correct.
   9   Q. What would you hope for?
  10   A. I would hope very much that one result would be to
  11     ensure that we can indeed meet the standards of quality,
  12     that we can improve care to acceptable levels in all
  13     parts of the country.
  14   Q. You would anticipate, or hope for, certain
  15     recommendations which would enable one to do that in
  16     a way one could not in the past?
  17   A. That is correct, including matters such as adequate
  18     staffing of specialist units.
  19   Q. So taking the staffing levels as one of the points which
  20     you obviously regard as having been inadequate in the
  21     past, speaking broadly for the moment, what else do you
  22     consider to have been less than ideal over the past 15
  23     years?
  24   A. I suppose, well, apart from the staffing which
  25     incorporates the large extra workload that has been

   1     imposed on the profession by various administrative
   2     matters and accountability matters, I would also hope
   3     that we can ensure that all consultants in the country,
   4     in all specialties, continued to maintain and improve
   5     their standards, their practice and their knowledge,
   6     throughout their working career, which, in most
   7     professions, was a tacit assumption but without any
   8     obligation in the past.
   9   Q. So you want to see what was a tacit assumption become an
  10     obligation enforced by sanctions?
  11   A. Yes, encouraged by sanctions.
  12   Q. The college itself, you tell us, and this is the bottom
  13     of 32/1, please, had for many years the view that it set
  14     the standards. That is paragraph 2, and it is
  15     a quotation from the aims of the Royal College.
  16        If we go to 32/2, you say that in the immediate
  17     future the college will most probably have a new
  18     statement of purpose which is underpinned by seven
  19     strategic activities defined as to set and improve
  20     standards?
  21   A. Correct.
  22   Q. So the College is moving from setting standards to
  23     setting and improving standards?
  24   A. That is correct. I think it is very important that this
  25     is explicit rather than implicit and does separate

   1     direction for many of our activities in the future.
   2   Q. We note from the opening paragraph, the four lines on
   3     page 32/2, that the mission is not simply to set
   4     standards but to promote the highest standards, and that
   5     itself with the purpose to improve health and health
   6     care?
   7   A. Correct.
   8   Q. That makes a difference, does it, to the way in which
   9     the Royal College of Physicians anticipates its role in
  10     the coming years?
  11   A. I think it was always implicit before, but by spelling
  12     it out, it gives very clear direction to the officers of
  13     the College and the fellows of the College of what our
  14     aims are. And I think will nudge everything up a bit,
  15     rather than saying, "Oh, well, this is all right". We
  16     always want people to say, "How can it be better?" That
  17     will have to be achieved within a financial framework
  18     and a working framework, but it will certainly give me
  19     the remit to push and press government and any other
  20     agencies to achieve these aims.
  21   Q. Going back to the function of the Royal College of
  22     Physicians as it was, the setting of standards rather
  23     than the setting and improving of standards, that
  24     phrase, "setting the standards", is aspirational in
  25     tone. Did it amount to stating the ideal and hoping

   1     that individuals and hospitals would achieve that
   2     target?
   3   A. It tended towards the pragmatic, and that is setting
   4     acceptable standards which we thought could be met.
   5     Setting the highest standard, if you just do that, then
   6     people will say, "Oh, well, that is not attainable". So
   7     it was setting what were good standards for the
   8     conditions of the time. But always nudging upwards even
   9     then.
  10   Q. So let me just look and see how, in the years with which
  11     we are principally concerned, from 1984 to 1995, the
  12     standards which were set were, if I use the word
  13     "enforced", you will understand that I cannot, I think,
  14     say that there was any enforcement, because there was
  15     not, effectively, was there?
  16   A. No, we did not have the power to enforce. We had the
  17     power to recommend, and as an ancient body which was
  18     reasonably well thought of, people listened, we hoped,
  19     and then acted according to whatever they thought was
  20     right. So we had no powers of enforcement, except for
  21     a limited number of things.
  22   Q. If we look, indeed, at the Form of Faith which each
  23     physician would have signed as a condition of
  24     fellowship, it is 32/16. Ignoring for a moment the
  25     amendment which is off the bottom of the screen which

   1     has recently been introduced, throughout the years with
   2     which we are concerned it appears that a fellow would
   3     have submitted himself or herself to such penalties as
   4     may lawfully be imposed for any neglect or infringement
   5     of ... the Bye-Laws and regulations, and do every
   6     professional to the honour of the College and the
   7     welfare of the State.
   8        Was there anything explicit in that promise which
   9     gave the Royal College any ability to remove from
  10     fellowship any physician who was thought to be
  11     incompetent?
  12   A. We state under Bye-Law 168 of the Conditions for Removal
  13     of the Fellowship or Membership, which is I think
  14     something you have received, that if you have obtained
  15     the licence by fraud, false statements, if you made up
  16     your qualifications, which occasionally happens, but
  17     more important, if you have been guilty of any great
  18     crime of public immorality or have acted in any respect
  19     in a dishonourable or unprofessional manner or violated
  20     any statutes et cetera, we can then admonish, reprimand
  21     or, with a two-thirds majority, can declare such fellow
  22     not to be a fellow of the College.
  23   Q. We will have a look at that. It is 32/17, please. We
  24     can see in the fifth line down, "guilty of any great
  25     crime", a lovely phrase,"or public immorality, or acted

   1     in any respect in a dishonourable or unprofessional
   2     manner".
   3        So there is nothing there about clinical
   4     competence?
   5   A. I would say someone who was clinically incompetent was
   6     unprofessional, but that of course is a matter for
   7     judgment. That is one of the problems, and I suspect
   8     that Bye-Law 168, I know it was invoked about seven or
   9     eight years ago, but it tended to be invoked only when
  10     someone had been brought up before the General Medical
  11     Council and struck off.
  12   Q. I was going to ask: throughout the period 1984 to 1995,
  13     how many physicians were removed from fellowship who
  14     were acting unprofessionally, the grounds being
  15     incompetence?
  16   A. That I cannot answer. I suspect a small number.
  17   Q. Impressionistically, how small? On the fingers of one
  18     hand?
  19   A. A handful I would guess, but I will let you have that
  20     information in writing afterwards.
  21   Q. I would be grateful. If only a handful, it would follow
  22     that the examples of professional incompetence would be
  23     the very extreme?
  24   A. Correct.
  25   Q. And therefore, if I can use the expression, the "merely

   1     incompetent" would have nothing in particular to fear
   2     from the College of Physicians so far as their
   3     fellowship is concerned?
   4   A. No. I think more important is the role of the General
   5     Medical Council who have the statutory ability to remove
   6     the powers of an individual to practice. They are the
   7     punitive arm by and large of the profession.
   8   Q. They will come and give evidence before us, and we can
   9     ask them and will ask them about that.
  10        As I understand what you say in your witness
  11     statement, you say that the Royal College of Physicians
  12     sought to achieve the standards it had set by a number
  13     of means. I will go through those which I have
  14     identified and you can tell me first if I am right and
  15     secondly if I have missed anything.
  16        Those which I have identified from your statement
  17     are by giving training approval; secondly by the
  18     approval of job descriptions for consultants and now
  19     non-consultant career grade doctors. Thirdly by
  20     providing representatives on advisory appointment
  21     committees. Fourthly, by the work of the Research Unit
  22     producing studies and reports on clinical care.
  23     Fifthly, possibly, by collecting and using data, in
  24     particular associated with junior staff in medical
  25     training and continuing medical education. Sixthly, by

   1     exercising the duty to approve the quality of training
   2     which doctors receive in posts in support of the
   3     appointment.
   4        That is a phrase I want to come back to, because
   5     I am not sure I fully understand it. It is taken,
   6     lifted, in terms, from your statement. Now, have
   7     I missed anything?
   8   A. I think the production of informative reports would
   9     certainly assist. In this context, for example, the
  10     three reports that I have with me of the Joint
  11     Cardiology Committee of the Royal College of Physicians
  12     and Royal College of Surgeons, and they would set
  13     standards, again, not legally enforceable, but highly
  14     influential. In the last year, for example, a report on
  15     the minimum size of a hospital which can safely
  16     undertake acute medicine and surgery, and that report
  17     has already had an impact on local services.
  18        So those reports are influential in setting safety
  19     marks, actually, as much as anything, for good practice.
  20   Q. Is any of the list which I gave you wrongly included?
  21   A. No. Some of them have statutory power such as the
  22     appointment of advisory committees, a representation
  23     thereon. Others are things we do, Specialist Registrar
  24     training we do on behalf of the STA which has statutory
  25     responsibility which it devolves to us.

   1   Q. Can I then look at some of those particular ways in
   2     which standards were maintained or achieved, or
   3     supported? I am trying to avoid the word "enforced."
   4        The first of those, obviously, is training. If
   5     you take your statement, and let us go, please, to
   6     32/12, what you say in paragraph 25, the foot of the
   7     page, under the role heading:
   8        "Consultant's role in training and supervision",
   9        "Training mechanisms have changed over the years,
  10     with training evolving gradually from the informal
  11     'apprenticeship' model to a more structured system in
  12     line with the Calman reforms of training. Mechanisms of
  13     review, assessment and quality control, are now much
  14     more clearly defined."
  15        Just pausing there, the use of the word "now" in
  16     "now much more clearly defined" implies, may even state
  17     that formerly mechanisms of review assessment and
  18     quality control were not very clearly defined?
  19   A. I would say were less clearly defined. It is a question
  20     of everything we do in the College and I think in any
  21     profession, the continuous improvement that goes on over
  22     decades.
  23   Q. There was, then, was there, some system of assessment
  24     and quality control throughout the period with which we
  25     are principally concerned?

   1   A. Of posts, of the training posts. I think the difference
   2     now is that each individual trainee is assessed in
   3     detail very carefully during the course of their
   4     training, which is a shorter training, actually. At the
   5     time in question, each post was visited and assessed
   6     very carefully with whoever happened to be the incumbent
   7     to ensure that that post was suitable for training.
   8   Q. I derive from your statement, that indeed there were two
   9     forms, as it were, of accreditation that were at work:
  10     one was the accreditation of an individual to
  11     a particular post or as fit for a particular post, and
  12     the second was the accreditation of a hospital or a unit
  13     as suitable to train a doctor?
  14   A. Correct.
  15   Q. I want to be careful when I use the word "accreditation"
  16     as to which of those two I may be talking about.
  17        May I look first at the individual level, before
  18     I look at the hospital level? I think what you are
  19     saying is that the trainee was not assessed until recent
  20     developments?
  21   A. Was not assessed in such formal detail. They would have
  22     to be written up by the consultants with whom they have
  23     worked during the course of their four or five years'
  24     training.
  25   Q. That would involve a large element of the subject?

   1   A. It would, indeed.
   2   Q. Was there any form of independent review of those
   3     subjective assessments?
   4   A. No, there was not, at the time.
   5   Q. Was any allowance made of the fact that, anecdotally,
   6     some consultants reporting upon their trainees may have
   7     been known to be hard task-masters, and others, as it
   8     were, soft touches?
   9   A. I suspect a little subjective interpretation may have
  10     crept in, but I cannot really speak for the JCHMT of the
  11     time that would give the approval.
  12   Q. In any event, if your suspicion is justified, there
  13     would be no empirical basis for it?
  14   A. No.
  15   Q. Can we, in the context of the individual, look, please,
  16     at the position in 1987, where you helpfully provided us
  17     with your third exhibit, the Joint Committee on Higher
  18     Medical Training handbook for 1987. For our purposes,
  19     if we can go over the screen to 32/23, is it on the
  20     screen in front of you?
  21   A. Yes, it is.
  22   Q. There in the second paragraph:
  23        "The responsibilities of the Joint Committee [this
  24     is 1987] are to formulate guidelines for training in the
  25     medical specialties, to approve [again what you have

   1     been saying] posts and training programmes which are
   2     suitable for higher medical training and to grant
   3     certificates of accreditation [talking about individual
   4     accreditation here] to those who have completed higher
   5     medical training."
   6        Those were the responsibilities, then, of the
   7     Joint Committee at least until 1987, and I think
   8     throughout most of the time with which we are concerned?
   9   A. Correct.
  10   Q. If we may go to 32/35, please, "Accreditation", the
  11     third paragraph down:
  12        "In single specialty accreditation" that would be
  13     the sort of specialty that cardiology or paediatric
  14     cardiology would be, would it?
  15   A. Yes, but it would be rare for anyone to do that on its
  16     own.
  17   Q. So they would do what, a dual specialty?
  18   A. They would either do cardiology in addition or general
  19     internal medicine, because it took time for people to
  20     move from GIM from the adult medicine, adult cardiology,
  21     to paediatric training followed by paediatric
  22     cardiology. So they were much more likely at that time,
  23     I would have thought, to train in paediatrics with
  24     a specialty of paediatric cardiology. That is true to
  25     this day, where we are encouraging in adult medicine all

   1     cardiologists to get a good training in general internal
   2     medicine as well, in addition. And about 60 per cent do
   3     that.
   4   Q. We see in the third paragraph that if it were a single
   5     specialty, "a trainee must complete a minimum of two
   6     years in the UK in a Senior Registrar graded training
   7     programme approved by the Joint Committee on Higher
   8     Medical Training for clinical training in that
   9     specialty."
  10   A. Correct.
  11   Q. If we go back to 32/29, the way in which a Senior
  12     Registrar would become a consultant and move out of the
  13     trainee grade would be principally by examination, would
  14     it?
  15   A. Moving from general professional training through into
  16     specialty training?
  17   Q. Yes.
  18   A. Yes, and I mean, now, certainly, and I think it would
  19     apply then, it was a sine qua non to have passed your
  20     MRCP in either general adult medicine or paediatrics
  21     before you obtained a Senior Registrar post, or
  22     nowadays, Specialist Registrar post.
  23   Q. The nature of the examination was written, was it?
  24   A. It is a mixture of written, clinical and oral, and was
  25     at that time.

   1   Q. And was at that time?
   2   A. It is very rigorous and complained about greatly.
   3   Q. Did it, so far as the MRCP was concerned, for
   4     paediatrics, involve a number of alternative-answer
   5     questions?
   6   A. Yes, indeed.
   7   Q. About 60?
   8   A. There was a multiple choice question format at that
   9     time.
  10   Q. If a doctor could successfully negotiate the 60 or so
  11     multiple choice questions, he would pass the written
  12     part of the examination. How was the clinical
  13     competence measured?
  14   A. That was done by both a certain amount of
  15     problem-solving, but also by examination of patients in
  16     the presence of two examiners, and questioning of the
  17     candidate about his or her findings. So it included
  18     actually not only, you know, was your knowledge all
  19     right, but were you manually or technically competent,
  20     and also, what was your attitude towards patients? We
  21     have failed people, and do fail people, if they are
  22     rough with patients or if their communication skills are
  23     lacking. That occurs even in medicine.
  24   Q. What proportion of the results was accounted for by the
  25     written exam as compared to the test of clinical

   1     competence?
   2   A. Well, the written you would have to pass. Part 1 was
   3     the multiple choice questions. Then part 2 would
   4     encompass both a further written component and if you
   5     pass that, then the clinical component. So it was
   6     a step-wise progression, so you could not, in fact, pass
   7     the whole exam without passing all components
   8     sequentially.
   9   Q. Once passed, was there any continuing test of competence
  10     or knowledge?
  11   A. There was no formal test, until we introduced the new
  12     Specialist Registrar system, getting on for 3 years ago
  13     now -- 2 and a half years ago.
  14   Q. It is really outside our terms of reference?
  15   A. It is outside, yes.
  16   Q. It is coming?
  17   A. It is coming.
  18   Q. If we look at the course or nature of the training,
  19     I think you see in 1987 that is set out at witness
  20     32/41. For paediatric cardiology, general professional
  21     training includes 6 months neonatal paediatrics,
  22     6 months in general paediatrics, one year in audit or
  23     paediatric cardiology, higher professional training,
  24     obligatory experience 4 years in approved training in
  25     paediatric and adult cardiology, progressing towards

   1     full specialisation in paediatric cardiology.
   2        That, essentially, was it. That was the course,
   3     as it were, as laid down in 1987?
   4   A. Yes.
   5   Q. May we compare that with what we now find at 32/122?
   6     This is September 1996. It is the curriculum for higher
   7     specialist training in paediatric cardiology?
   8   A. Yes, I have it.
   9   Q. If we just simply flick over the pages, one can see 123,
  10     which introduces the curriculum and deals with general
  11     professional training halfway down the page, research,
  12     higher professional training, 32/124: a first year
  13     target. 125, the middle of the page, second year
  14     target, 126, the third, fourth, fifth year target and
  15     helpfully summarised at 127.
  16        This curriculum is undoubtedly much more detailed
  17     than the former curriculum?
  18   A. Much more so, and is part of the evolution that we have
  19     undergone towards much more explicit curricula, which
  20     have their problems as well, however.
  21   Q. It is much more prescriptive?
  22   A. It is, and it assumes everyone learns at the same rate,
  23     which is an assumption I would hate to make.
  24   Q. But in general, has the change been because it has been
  25     found to be necessary?

   1   A. It was felt -- which I agree with, certainly -- that it
   2     was necessary to be much more explicit. I am not, with
   3     that comment, suggesting that training was or was not
   4     bad at the time in question, but it certainly has been
   5     felt over this last few years that things have to be
   6     spelled out much much more clearly, and I certainly,
   7     personally, feel that to do this and then to assess
   8     people in a more formal capacity is necessary.
   9   Q. Am I right in thinking that it must be the experience of
  10     the past which has led to the conclusion that the former
  11     curriculum was insufficient? For the purposes we would
  12     now set ourselves.
  13   A. I think in part that is correct. If you go back to the
  14     1960s, where there were no curricula at all, and the
  15     JCHMT was founded, that was an even bigger change when
  16     it was just assumed, if you worked with a decent boss,
  17     you would be a decent consultant, and of course, I am
  18     sure the same is true in your profession. That changed
  19     quite drastically, and this is now a refinement of that
  20     change.
  21   Q. Where the change perhaps does not yet take us, and
  22     I invite your comments, we may see from 32/96. Just to
  23     identify the document, if we flick back to 32/95 and
  24     then forward to 96 again, please, this is the revised
  25     composition and constitution of the JCHMT 1998, so this

   1     is the latest, is it?
   2   A. That is correct.
   3   Q. At the bottom of 96, the roles and responsibilities of
   4     the JCHMT, which you describe as the "training arm" of
   5     the Royal College?
   6   A. Yes.
   7   Q. And on behalf of the Colleges, the bottom of the page,
   8     it will:
   9        "(a) review and update curricula; (b) approve
  10     higher medical training programmes; (c) confirm the
  11     fulfilment of entry requirements and provisional CCST
  12     date."
  13        Then the next page. We can run an eye through (d)
  14     to (i), and it would be right, would it, to say that
  15     there is no reference there in the JCHMT constitution,
  16     at any rate, to any requirement to achieve any
  17     particular standard in continuing medical education?
  18   A. No, but it is assumed -- I certainly make that
  19     assumption as a full member of the JCHMT, that part of
  20     the assessment and of the appraisal will be to ensure
  21     first that people have gone through a full training
  22     programme, and secondly, that they have achieved
  23     a degree of competence within their specialty, an
  24     appropriate degree of competence.
  25   Q. The person I am asking about is the person who, having

   1     achieved and displayed the degree of competence and
   2     knowledge, sadly ceases to do so after an interval of
   3     time. There is no mechanism, as I understand it, in
   4     training and education through the JCHMT, at any rate,
   5     to identify such a person, or to ensure that the
   6     incidence of such a person is limited?
   7   A. The JCHMT only deals with people in the Specialist
   8     Registrar training grades, so within that framework, if
   9     someone proved incompetent, they would be referred for
  10     further training, and maybe, after that, if still not
  11     deemed competent, would be advised to seek other
  12     employment.
  13   Q. But it is a threshold provision, is it not: once you are
  14     in, once you have crossed the barriers of exams and have
  15     your CCST?
  16   A. That is when you are then beyond Specialist Registrar.
  17     You are no longer a Specialist Registrar once you have
  18     the CCST. That takes you straight into the question of
  19     testing consultants for competence and ability to
  20     practice over the next 30 years.
  21   Q. Which is no part of the JCHMT?
  22   A. No.
  23   Q. But becomes part of?
  24   A. And that is one of the college's responsibilities,
  25     relatively new-found, and it is amazing to think of it

   1     now but it was always assumed in all professions that it
   2     was your professional duty to keep up to date and
   3     maintain good practice, and far the majority of people,
   4     of course, did so and attended meetings and continued
   5     learning, but a substantial minority, I suspect, did
   6     not. That has now been formalised. Three or four years
   7     ago, continuing medical education was introduced as
   8     a voluntary process, where you had to sign up to 50 to
   9     100 hours per year of particular forms of attendance at
  10     educational sessions, and we had the process of refining
  11     that and that will become compulsory, and will include
  12     a degree of self assessment that we at the College will
  13     see the results of.
  14        So I think that whole area is a relatively new one
  15     for our profession, and is one, certainly for hospital
  16     medicine, but is one that is being worked on now, and
  17     before I either get stabbed in the back or leave the
  18     College, I would hope to see formally in place.
  19   Q. Even at today, am I right in thinking that there is no
  20     obligatory requirement to indulge in continuing medical
  21     education?
  22   A. As of today. Of course, there is major peer pressure so
  23     to do, but that is one of my aims within the next two to
  24     three years, when we have a good CME system operating,
  25     that it will be compulsory.

   1   Q. You say in your statement, 32/14, the very top, talking
   2     about the CME programme, that although approximately
   3     80 per cent of all physicians are part of it, you know
   4     that only 15 out of 53 consultants in paediatric
   5     cardiology are formally enrolled in the CME programme?
   6   A. I noticed that, too.
   7   Q. It is less than 30 per cent?
   8   A. I think it is open to several interpretations, believe
   9     it or not. Paediatrics, as you know, formed its own
  10     college a couple of years ago, two years ago, and
  11     a certain number of paediatricians, or paediatric
  12     cardiologists, will be general paediatricians with an
  13     interest in cardiology; others will be formal paediatric
  14     cardiologists. Some of them, and we are trying to find
  15     out how many, will be enrolled with the College of
  16     Paediatrics and Child Health, where there is this
  17     unsatisfactory position really of paediatric cardiology
  18     having been left behind at the College of Physicians
  19     because of its very strong links with adult cardiology,
  20     and this is something we need to clarify. It has been
  21     very helpful in making us look at this information.
  22   Q. You say quite frankly in your statement you do not know,
  23     really, how many paediatric cardiologists are undergoing
  24     CME?
  25   A. We do not, and we will try to establish that.

   1   Q. So the 15 out of 53, is that 15 out of the 53 who have
   2     retained their membership, their fellowship, in the RCP?
   3   A. No. I mean, no-one has, or very few have, actually
   4     resigned their fellowships. Most are now fellows of
   5     both colleges. Those are the 53 consultants in
   6     paediatric cardiology whom we could identify by whatever
   7     means.
   8   Q. But the 15 is the 15 who are registered through you?
   9   A. The 15 are those who have responded to us, although all
  10     38 others will have had a letter from the three
  11     Presidents indicating the unsatisfactory nature of their
  12     behaviour at this time.
  13   Q. If the figure were at all accurate, then it may indicate
  14     something about the degree to which peer pressure would,
  15     in the past, have influenced paediatric cardiologists?
  16   A. That is possible, although there are a lot of different
  17     reasons for not formally signing for CME. CME as it
  18     stands at the moment, you get points for attending
  19     meetings of different sorts, and some people feel this
  20     is, you know, (a) they attend far more meetings than are
  21     required anyway, and they do not want to spend yet extra
  22     administrative time filling in little diaries and forms,
  23     and we have had one or two quite vociferous letters from
  24     adult cardiologists on that point, extremely good
  25     cardiologists. Others feel that sitting in a lecture

   1     theatre -- you know, the 'bums on seats' approach, which
   2     is what it is at the moment -- is not the best way of
   3     learning, and I certainly agree with them there. So
   4     there are reasons for not signing up to the current
   5     position which is being refined rapidly by the College.
   6   Q. I want to go back to the comment you made about the
   7     perhaps natural resistance for people who wish to be
   8     doctors, to become form-fillers. Am I right in thinking
   9     this is at least an attitude which a significant number
  10     of the profession have?
  11   A. Had.
  12   Q. And had throughout the period with which we are
  13     interested?
  14   A. I would imagine so. I think the whole ethos is changing
  15     very rapidly and people are accepting, for example, the
  16     need to keep good records for audit purposes, and the
  17     need to be seen to be accountable. I think that is
  18     a change, a big change, amongst all my professional
  19     colleagues from a system which operated comfortably, if
  20     not necessarily well, for hundreds of years.
  21   Q. And secondly, I think it is recognised that paediatric
  22     cardiologists at any rate are amongst the most
  23     overworked or hard-worked in terms of demands on time?
  24   A. That is absolutely right.
  25   Q. I have dealt thus far, I think, with the training at

   1     individual level and continuing training and how that
   2     related to the past.
   3        Can I turn to the allied question of accreditation
   4     of the hospital, the post for training purposes, with
   5     particular reference to 1984 to 1995?
   6        You say, at page 7, in a slightly different
   7     context -- it is paragraph 15 -- that the College has
   8     always been involved in setting standards through
   9     a number of wide approaches.
  10        Do you mean a wide number of approaches, or
  11     a number of wide approaches?
  12   A. A wide number of -- well, no, a series of different
  13     approaches.
  14   Q. Including the reports of College working parties which
  15     have considered and reported on particular service and
  16     health issues. Then you say this:
  17        "The subject matter is generally identified as an
  18     issue of concern by listening to the operational
  19     experience of fellows and members."
  20        This is, is it, physicians talking to one another
  21     about their experiences?
  22   A. In part. I cannot answer for exactly what would
  23     determine these things 15 years ago, but today, a lot of
  24     or several of the reports we are working on are on
  25     problems that have been identified to me by many

   1     physicians and trainees as I have stumped around the
   2     country listening to people's complaints, and sometimes
   3     positive suggestions.
   4   Q. You are not yourself a cardiologist, as we know, but the
   5     position would be this, would it: that people within
   6     a specialty tend to know those others within the same
   7     specialty?
   8   A. Correct.
   9   Q. And they tend to talk to those others, and sometimes
  10     about those others?
  11   A. Correct.
  12   Q. So there is, as it were, a general knowledge in one part
  13     of the country as to what might be the concerns or
  14     problems in another part of the country?
  15   A. That is often the case, yes.
  16   Q. That is, as it were, a colloquial approach: people just
  17     talking about it to each other, and not at all formal?
  18   A. Yes.
  19   Q. Can I give you a for instance? Could I ask you to have
  20     a look at a document we have at UBHT 133/68?
  21        It is a letter on 12th June 1987 from or written
  22     on behalf of the Children's Heart Circle in Wales. You
  23     do not need to be concerned with the addressee, but what
  24     I want to ask you about is what might happen or what you
  25     might have expected to have happened in 1987, given some

   1     of the matters which are stated in the letter.
   2        I must emphasise that they may or may not be
   3     accurate.
   4        What is said by the author of the letter, the
   5     second paragraph, the second sentence:
   6        "Three consultant cardiologists of such
   7     qualification, experience and present position to be
   8     well-placed to make such judgments, expressed concern
   9     about Bristol. The three were from different health
  10     authorities; they volunteered their information
  11     independently ..."
  12        He goes on to deal with the way in which he, the
  13     author, attempted to cross-reference one with the
  14     other.
  15        He says in the last paragraph:
  16        "Concern about Bristol has also been revealed as
  17     one reason why a very well respected paediatric
  18     cardiologist did not apply for the post in Cardiff
  19     (which is tied in to Bristol) and the reason for another
  20     specialist withdrawing his application."
  21        I suppose one could go back to the second last
  22     sentence in the previous paragraph:
  23        "All three consultants contended that concern was
  24     widely held."
  25        If that were right, there would be a body of

   1     concern amongst cardiologists, who would undoubtedly be
   2     members of the Royal College of Physicians. You are
   3     nodding. That does not go down on the transcript.
   4   A. Yes.
   5   Q. In 1987, Bristol did have a training role?
   6   A. Correct.
   7   Q. And what I am interested to explore is how expression of
   8     concerns such as these, if they were known of, at least
   9     anecdotally in the colloquial conversations which I have
  10     referred to, which you accept as generally taking place,
  11     might have manifested themselves in some action in
  12     respect of Bristol, at least to investigate the concerns
  13     and, if they were justified, to do something about them.
  14        The accreditation of a unit for the purposes of
  15     training I think we can see was done on a number of
  16     bases. If we look again at 1987, which is partly why
  17     I chose the letter that you see there, for the sake of
  18     example, can we go to 32/31, "The role of the JCHMT":
  19         "Recognition of post/training programmes for
  20     higher medical training."
  21        It begins to describe, towards the bottom of the
  22     page, how a specialist advisory committee may recommend
  23     a visit to assess training. The visiting team is then
  24     guided by a number of principles.
  25        Did a unit, once approved for training, have to be

   1     reassessed every five years?
   2   A. That was the intent, certainly.
   3   Q. Did teams in fact go around?
   4   A. I do not have specific information on paediatric
   5     cardiology visits in Bristol, and will continue to try
   6     to dig in the College archives for these. They are in
   7     the cellar somewhere. But certainly, I know in my own
   8     specialty where I sat on the SAC that there was
   9     a rigorous and repeated series of visits and that if
  10     a visit proved unsatisfactory, then there was a repeat
  11     visit one year later, with the intent being that the
  12     home base had a chance to put things right. If they did
  13     not, you could then withdraw recognition from that place
  14     for training.
  15   Q. I accept the theoretical "could". Just looking at the
  16     period 1984 to 1995, did it actually ever happen?
  17   A. I know of a case certainly outwith paediatric
  18     cardiology. What I do not know is whether it occurred
  19     in paediatric cardiology. I think we should also
  20     remember at this time that paediatric cardiology had
  21     a manpower crisis. There were insufficient trainees
  22     entering paediatric cardiology for the number of posts
  23     needed to start the specialty properly.
  24   Q. Does that imply that any assessment as to whether
  25     a training post should remain open is likely to be made

   1     in more relaxed criteria?
   2   A. I think that people would be more sympathetic, but
   3     I think they were more keen -- I mean, there may have
   4     been posts which were vacant and when a trainee came in,
   5     they would be assessed. I know that they have done
   6     that, but I know there was concern at the time about
   7     inadequate numbers of people wanting to do this very
   8     stressful specialty.
   9   Q. I appreciate you correct my word "relaxed" and come to
  10     your words, perhaps more sympathetic. Was the end
  11     result the same: that the assessment team might make
  12     a recommendation in another specialty for the withdrawal
  13     of training accreditation, whereas with paediatric
  14     cardiology, given the manpower crisis, they would not?
  15   A. No, I do not think that is true, actually.
  16   Q. So how does the sympathy work?
  17   A. I think people are basically sympathetic to the needs of
  18     the unit in terms of just workload, but I mean, you
  19     would still have your set of criteria which are outlined
  20     here, against which you would judge that unit.
  21   Q. Just to look at those criteria, if we may:
  22        "(i) there should normally be more than one
  23     consultant in the relevant specialty, each with
  24     a minimum of five sessions (or its equivalent) ...
  25        (iv) posts should provide facilities which will

   1     allow the best standards of specialist practice,
   2     including facilities for appropriate clinical
   3     investigation and management."
   4        How were the best standards of specialist practice
   5     to be judged in 1987?
   6   A. By peer review. I do not think there would be, you
   7     know, any explicit series of written down standards.
   8   Q. So there would be nothing empirical about it?
   9   A. I cannot think what there would have been. I do not
  10     know, is the answer.
  11   Q. "(v) attention will be given to the available clinical
  12     experience as shown by the turnover of both inpatients
  13     and outpatients. There should be an up-to-date records
  14     system."
  15        So the absence of an up-to-date records system
  16     would undoubtedly count against accreditation?
  17   A. Yes.
  18   Q. The turnover of inpatients and outpatients appears to
  19     look at the numbers?
  20   A. Yes.
  21   Q. In other words, is the trainee getting sufficient
  22     experience?
  23   A. If you only see one or two cases of a particular sort,
  24     then you would deem that training not to have gained
  25     sufficient experience.

   1   Q. That in part is the reason why there should be more than
   2     one consultant?
   3   A. That, in part, and also because if there is only one
   4     consultant, the time he has for teaching and instructing
   5     a trainee is greatly diminished, because they are just
   6     too busy clinically.
   7   Q. Would it matter at all -- I appreciate I may be taking
   8     you outside your specialty and, if I am, please tell
   9     me -- that a given site had particular difficulties by
  10     having a split between the place where the cardiologist
  11     would principally practice, say a children's hospital,
  12     with the open heart surgery conducted down the road at
  13     a different site? So there would be a problem of
  14     liaison between at least the cardiologist, or might be
  15     a problem of liaison between the cardiologist and the
  16     cardiac surgeon?
  17   A. I suspect it would have been a matter for concern, and
  18     I would have expected a visiting team to explore very
  19     carefully how that problem was overcome. But again,
  20     I suspect that pragmatically, one would accept that it
  21     might take years for something like that to be corrected
  22     and, if there were reasonable interim measures, that
  23     would have been accepted for a time.
  24   Q. Just summarising where we have got to on this line of
  25     questioning, I think what you have told me is that you

   1     do not know, but you will find out, whether in fact any
   2     assessment team had a look at the cardiology training in
   3     Bristol.
   4   A. Yes.
   5   Q. If it were to look at the cardiology training in
   6     Bristol, it would form an impressionistic view, it could
   7     do nothing else, of the quality of care there provided,
   8     and it would have some significant regard to the numbers
   9     of cases and the amount of consultant time devoted to
  10     paediatric cardiology?
  11   A. Yes.
  12   Q. Can I, in the light of the numbers, just take you to two
  13     reports which you have produced as annexes to your
  14     statement, and ask you first to look, if you please, at
  15     page 32/18, to identify the report.
  16   A. Correct.
  17   Q. This is the third report of a Joint Cardiology Committee
  18     of the RCP and the RCS, January 1985.
  19        If I can --
  20   A. It is not what is on my screen, but I have it in front
  21     of me.
  22   Q. I am sorry, it should be 218. I am grateful. We now
  23     have the third report. Thank you for correcting me.
  24        If we go to page 220, there is a summary before
  25     the text of the principal conclusions, paragraph 5:

   1        "Cardiac centres currently undertaking invasive
   2     investigations and cardiac surgery need to expand to
   3     cope with demand. A target figure of 750 to 1,000
   4     bypass operations annually is suggested. This implies
   5     3 or 4 surgeons and 6 cardiologists per centre. Other
   6     staffing should be based on these figures. Smaller
   7     centres are not necessarily non-viable, but should be
   8     encouraged to expand or merge.
   9        "7 supra-regional centres for the cardiac problems
  10     of infants under the age of one year have been
  11     identified and should receive supra-regional funding.
  12     Their staffing and equipment should be appropriate to
  13     the exceptional demands of this work. If such a centre
  14     is sited within an existing cardiac centre, the staff
  15     will be additional to those needed for the adult work.
  16     Facilities for older children should continue to be
  17     provided, as at present, at all cardiac centres."
  18        So looking at "Principal conclusions" for
  19     a moment -- I want to go to the text in a minute -- the
  20     target figure is 3 or 4 surgeons and 6 cardiologists,
  21     plus the surgeons and the cardiologists needed for the
  22     infants under the age of 1?
  23   A. Correct.
  24   Q. If we then go to 224, where the size of cardiac centres
  25     is dealt with in greater detail, it deals first of all

   1     with the second report. I do not want to read it out,
   2     given the time, at length.
   3        If I can direct you to about halfway down, where
   4     it says "In 1980 ..."; can you find that?
   5   A. Yes.
   6   Q. "In 1980 the recommendation was that with at least three
   7     surgeons in every unit, 600 bypass operations should be
   8     performed annually." And then is says this, "Since
   9     surgeons undertaking less than 200 operations a year
  10     often had results with higher than average mortalities."
  11        Pausing there for a moment, that is stated as
  12     a bald fact; it is not referenced. Plainly, it was the
  13     general view of those experienced members who compiled
  14     this third report?
  15   A. I accept that, yes.
  16   Q. Given the difficulties which you have already adverted
  17     to in respect of record-keeping and audit, how is it
  18     likely that this would have been calculated?
  19   A. I think -- well, two things: (1) that there were systems
  20     introduced for audit of cardiac operations before this
  21     time for adult cardiac operations, and this is
  22     referring, of course, to adult operations.
  23   Q. Absolutely.
  24   A. So there would have been data available. Beyond that,
  25     I am not prepared, or not able, to make any useful

   1     statement, especially not on surgical territory.
   2   Q. In order to interrogate that, one would have to ask
   3     a member of the Working Party, would one?
   4   A. Yes, or ask one of my surgical colleagues, who will have
   5     this at his or her fingertips.
   6   Q. Ought to have, possibly.
   7        If we turn over, or go down to the bottom of the
   8     page, to "Staffing":
   9        "It follows from the previous paragraph that each
  10     centre should be staffed by 3, and preferably 4,
  11     consultant cardiac surgeons [again talking about adult
  12     surgery]. The second report emphasised the need to
  13     allow for the demands of emergency work, leave,
  14     sickness, teaching and research, as well as for clinical
  15     duties. In some centres in which thoracic surgery is
  16     also undertaken by surgeons primarily involved in
  17     cardiac work an additional surgeon may be necessary.
  18     The role of cardiologists has altered to some extent
  19     since the previous report, with a greater emphasis on
  20     coronary arteriography increasing on invasive
  21     interventions ..." and it sets those out.
  22        Then it says in its last sentence: "The committee
  23     repeats its earlier recommendation that the equivalent
  24     of 6 whole-time consultant cardiologists are desirable,
  25     the exact number depending on the degree of involvement

   1     of radiologists in invasive techniques."
   2        Then, with that in mind for adult cardiology, can
   3     you turn with me to page 226? The top of the page:
   4        "Supra-regional funding.
   5        "Infant cardiac surgery and its associated
   6     cardiological service (see below), and cardiac
   7     transplantation are carried out in only a few centres
   8     and as such should be funded supra-regionally."
   9        That takes us to the bottom of the page. It is
  10     the last full paragraph, beginning "The DHSS ..."
  11   A. Yes.
  12   Q. "... has recently endorsed the establishment of 9 such
  13     centres to be funded supra-regionally ..." and sets them
  14     out. "The Committee welcomes this development but
  15     stresses that as 9 centres are an absolute maximum,
  16     given the calculations made in the second report, no
  17     consideration should be given to the establishment of
  18     further such centres unless there is a considerable
  19     increase in workload which, at present, seems highly
  20     unlikely."
  21        Turning over to page 227, dealing with the
  22     supra-regional centre, it talks about general
  23     paediatricians, the top paragraph, and then, in the
  24     penultimate paragraph on the page:
  25        "The equipment of cardiac regional and

   1     supra-regional centres must enable them to provide
   2     a service free from interruption caused by breakdowns
   3     and repairs".
   4        It talks about the need to have two fully equipped
   5     catheterisation laboratories.
   6         "The staff in a supra-regional centre must
   7     include a minimum of 2 surgeons to maintain 24-hour
   8     year-round cover."
   9        Thus far, it appears to be talking about
  10     2 surgeons who do nothing but paediatric cardiac work.
  11     You nodded, I think?
  12   A. Yes.
  13   Q. In some centres they may also undertake adult work. The
  14     thrust of this is that that is subservient to the
  15     paediatric cardiology which they do?
  16   A. I would interpret it that way, yes.
  17   Q. To the paediatric surgery which they do. "The number of
  18     paediatric cardiologists may vary from 2 to 4 depending
  19     on the unit's size, or would normally have general
  20     paediatric expertise." So that is the sort of staffing
  21     level that the Joint Working Party would have been
  22     looking for?
  23   A. Yes.
  24   Q. It notes, and this is the last sentence, that those
  25     staff are extra, additional to, the other staff in the

   1     cardiac centre?
   2   A. Correct.
   3   Q. Coming forward in time, bearing in mind what is said
   4     about size, it proves to be the case, as I understand
   5     it, in practice that not only did supra-regional centres
   6     perform cardiac surgery on infants under the age of 1,
   7     but over time, one or two other centres began to do such
   8     work as well?
   9   A. I take your word for it, yes.
  10   Q. What I want to ask you about is this: that presumably
  11     was in part because of the idea that clinicians should
  12     be free to perform such surgery as they thought
  13     appropriate to the needs of the patient before them?
  14   A. That is one way of putting it, but I think the history
  15     of medicine has been that the development of new or
  16     difficult techniques in a small number of centres, as
  17     they became more practised and more usual, other
  18     surgeons would get training in those techniques and
  19     would diffuse them around to other centres, particularly
  20     if the need was seen to be increasing.
  21   Q. If one is talking about a relatively rare condition,
  22     hence supra-regional funding, and if one accepts that
  23     the whole raison d'etre of having regional or
  24     supra-regional centres is to allow for sufficient
  25     operations to be done in any one place to develop an

   1     expertise, quality of care, then it must be, must it
   2     not, adverse to the general public interest for an
   3     individual clinician, or small group of clinicians, to
   4     start doing those operations in some other centre?
   5   A. Unless they were well-trained and there was a clear need
   6     to develop further centres.
   7   Q. Who would identify the need?
   8   A. I suppose the waiting lists of those centres which were
   9     already doing the operations.
  10   Q. And the need might, of course, be met by referral?
  11   A. It could be met by referral, depending on the size of
  12     waiting list.
  13   Q. Did the Royal College of Physicians have any means of
  14     influencing decisions as to whether there should be
  15     a separate department established in another hospital
  16     beyond --
  17   A. We would have had no say, and I just re-emphasise that
  18     I am President of the College of Physicians, not
  19     Surgeons, and we would have had no say in
  20     recommendations purely on the surgical side.
  21   Q. But the surgery has to be supported by the cardiology?
  22   A. Correct, but if the surgeons recommend another centre,
  23     we would then support as needed, but it would not be our
  24     recommendation whether a further surgical centre should
  25     be established or not, as the case may be.

   1   Q. Are you saying if the surgeons chose to establish
   2     a centre?
   3   A. We would then comment on our ability to provide the
   4     support required, and then presumably have another
   5     meeting of the joint group to decide whether that
   6     support was available or when it was available.
   7   Q. Ultimately, in the past -- you appreciate I am asking
   8     about 1984 to 1995 -- if the choice had been that of the
   9     individual cardiologist to support the individual
  10     cardiac surgeon, if I say setting up on his own, it is
  11     very much a crude representation of what might have
  12     happened -- but if that were the position, would the
  13     Royal College of Physicians interfere in any way, even
  14     by seeking to influence that decision?
  15   A. I think at that time that is unlikely.
  16   Q. Now it would be different?
  17   A. I think now we would be much more interventionist on the
  18     grounds of safety, particularly, and quality.
  19   Q. What you are telling me is that in those particular
  20     years, at any rate, the Royal College of Physicians
  21     would hesitate to interfere or influence the exercise of
  22     clinical freedom upon the grounds that it perceived
  23     generally that the public interest lay in an opposite
  24     direction?
  25   A. I think that, first of all, if we were not informed that

   1     there were problems, we would not have any ability to
   2     interfere, other than informally.
   3   Q. So it would be reactive rather than proactive?
   4   A. Correct.
   5   Q. When it came to accrediting, perhaps a new unit set up
   6     in the way I have crudely outlined, would the approach
   7     of the Royal College of Physicians simply be to say,
   8     "Does it meet the check-list, and therefore can be
   9     approved as being a training establishment", or would it
  10     in the past say "We do not approve of a plethora of
  11     centres for a rare condition being established, and
  12     therefore we will not give training approval, training
  13     accreditation"?
  14   A. I think we would certainly have said that if there were
  15     an inadequate number of cases passing through for
  16     training purposes, then we would not give approval.
  17     That would in fact meet that particular requirement.
  18   Q. Can I briefly ask you about approach to audit?
  19        If we go to page 208, please, we are now looking
  20     at the fourth report of the Joint Cardiology Committee
  21     of the Royal College of Physicians of London and the
  22     Royal College of Surgeons of England. Page 238 I think
  23     is the last page of the text of that report.
  24        At paragraph 14 you deal with audit. You say
  25     this -- I say you, the College of Physicians, the joint

   1     working party:
   2        "At its simplest, medical audit involves peer
   3     review of a department or hospital which would encompass
   4     all clinical activities, including the in-patient and
   5     outpatient diagnostic services and the operating
   6     department."
   7        This is written in 1991.
   8        "It will review waiting list times as an indirect
   9     indication of provision, and outpatient waiting times as
  10     an index of one aspect of quality of service. It should
  11     permit comparisons between hospitals and regions, and
  12     also differences in national provision".
  13        Leave aside for the moment what is said under 142
  14     about national registries, but thus far, what was
  15     available for audit was very limited, was it?
  16   A. Yes. I mean, audit was a concept in a way. I mean,
  17     many of us would have checked our own results and made
  18     sure we were content with what was going on in our
  19     units. But the whole concept of audit was introduced
  20     with a bang by the Department of Health in the late
  21     1980s. The mid-80s became highly discredited very
  22     rapidly as being unhelpful, but was introduced more
  23     formally by colleges such as ourselves at the beginning
  24     of this decade, 1990, and has slowly picked up, enabling
  25     us to have comparative information with other units, and

   1     against national standards. It is really the next five
   2     years where this will really bite, although it has
   3     already begun.
   4   Q. In those days it seems to have been more a question of
   5     the throughput, does it?
   6   A. No. There would have been throughput on waiting lists,
   7     which is obviously important as well which is what the
   8     emphasis of the Department of Health was on at the
   9     time. They were not interested in results; they were
  10     interested in as many people passing through the system
  11     as possible for as low a cost as possible.
  12   Q. What one might call commercial considerations?
  13   A. Commercial considerations did seem to enter into it
  14     rather strongly. I think now we are rather interested
  15     in quality of care and outcome of care, although in many
  16     areas of medicine it is really extremely difficult to
  17     measure outcome with any meaning, or without totally
  18     submerging your staff in paper exercises, taking them
  19     away from clinical work. That is a constant battle we
  20     have.
  21   Q. At 14.4 under this 1991 paper:
  22        "All cardiac departments should co-operate with
  23     the audit activity of other specialties in their
  24     hospitals, hold regular audit meetings and maintain
  25     appropriate records."

   1   A. Yes.
   2   Q. The records which would be appropriate would be records
   3     which would enable one to understand the outcomes?
   4   A. Yes, and understand the process, as well. The process
   5     as well as the outcome. When it talks about
   6     "appropriate records", you can interpret that, of
   7     course, in many ways. It may just mean there is a clear
   8     indication at the end of the record of outcome of that
   9     patient, or it could mean that you should have
  10     cumulative records for all activities of the units.
  11     That is left very vague, though.
  12   Q. I was going to ask, you obviously were not yourself part
  13     of the drafting of this paper, but it is the Royal
  14     College of Physicians paper. It is annexed to your
  15     statement. Can you help us as to in which sense
  16     "appropriate" was there used, or was it deliberately
  17     left vague?
  18   A. I think it was deliberately left vague because of the
  19     imperfections which are still present of our IT systems,
  20     because to do all this by paper records is immensely
  21     time-consuming.
  22   Q. Again, because the process was one rather of exhortation
  23     rather than prescription?
  24   A. None of this is prescriptive. We were dependent on
  25     goodwill, common sense, and the co-operation of people

   1     who had other priorities in mind.
   2   Q. That is all, given the time, Professor Alberti, which
   3     I am going to ask you about. May I for my part thank
   4     you very much for your evidence. There may very well be
   5     some questions from the Panel.
   6             Examined by THE PANEL:
   7   MRS MACLEAN: Thank you very much. I will not detain you
   8     for very long. I just wanted to clarify, you described
   9     paediatric cardiologists as increasingly being
  10     associated with the College of Paediatricians, and you
  11     used the phrase "some are left behind at the Royal
  12     College of Physicians". Would I be right in thinking
  13     that you feel that they belong more comfortably with
  14     their fellow paediatricians?
  15   A. I think it is extremely difficult, which is why my
  16     statement sounded a little woolly, because cardiological
  17     purposes, I think it is very important they remain
  18     associated with cardiologists dealing with adults. They
  19     are, of course, firmly implanted in the Royal College of
  20     Physicians. For general paediatricians, they need to be
  21     associated with the Royal College of Paediatrics and
  22     Child Health, so I think what we will have is people who
  23     have some form of split allegiance and we need to define
  24     very clearly where the lines of accountability are.
  25        The JCHMT, that is, our college organisation,

   1     looks after paediatric cardiology for specialist
   2     training, but of course has representatives on it, the
   3     SAC from the Royal College of Paediatrics. So this is
   4     all relatively new and we are trying to make sure it is
   5     as efficient and effective as possible.
   6   PROFESSOR JARMAN: You said it is one of your aims to
   7     introduce compulsory CME, and in order to avoid you
   8     being stabbed in the back, which I would hate to see
   9     happen, can you tell me what recommendation would be
  10     most helpful to enable that to happen?
  11   A. I think the recommendation from you that it is evident
  12     that continuing lifelong education is essential for all
  13     consultants, and that this should be assessed at regular
  14     intervals.
  15   Q. Of what?
  16   A. Five years if practicable. We will have minor
  17     assessments on an annual basis. We are introducing
  18     that. But I think a five year assessment of performance
  19     and of CME would be helpful. That fits in with the
  20     revalidation proposals as well, of course.
  21   Q. Which you agree with?
  22   A. Totally.
  23   THE CHAIRMAN: Professor Alberti, I have no questions. May
  24     I therefore echo Mr Langstaff's thanks to you for
  25     coming -- and the Panel's thanks. We are much in your

   1     debt and are grateful to you for not only what you have
   2     said, but also what you have put in for us to read.
   3     Thank you very much.
   4   PROFESSOR ALBERTI: It is a pleasure, thank you.
   5             (The witness withdrew)
   6   MR LANGSTAFF: Sir, that would be an appropriate time,
   7     perhaps, to have a break until a quarter past 11.
   8   THE CHAIRMAN: Until a quarter past then, thank you.
   9   (11.00 am)
  10               (A short break)
  11   (11.20 am)
  12   THE CHAIRMAN: Miss Grey, I do apologise for being late;
  13     there was one technical matter we had to resolve.
  14   MISS GREY: Sir, we have two witnesses from the English
  15     National Board for Nursing, Midwifery and Health
  16     Visiting this morning. We have Mrs Susan Jane Marr and
  17     also Mrs Rita Le Var to give evidence. We were
  18     proposing, because of their respective posts and
  19     experience, that we should invite them to give evidence
  20     together and that we should therefore try and enable
  21     a discussion, rather than any formal sequential
  22     questioning. So, with your permission, I will invite
  23     them both to come up to the witness stand.
  24   THE CHAIRMAN: I think that is an excellent idea; thank
  25     you.

   1   MISS GREY: You will both have to bear with us whilst we do
   2     this. We may have initial glitches like proximity to
   3     the microphone and so on. I hope it works reasonably
   4     well. We have spoken to you about taking evidence on
   5     oath, and I think you have both indicated you would like
   6     to take the oath. Could I ask Mrs Marr, please, to take
   7     the oath first, if you would like to stand.
   8            MRS SUSAN JANE MARR (Sworn)
   9             MRS RITA LE VAR (Sworn)
  10             Examined by MISS GREY:
  11   Q. The English National Board has submitted a statement to
  12     the Inquiry from Mr Smith, and I think that you have
  13     both had an opportunity to read Mr Smith's statement,
  14     and you agree with its contents?
  15   MRS MARR: Yes.
  16   MRS LE VAR: Yes.
  17   MISS GREY: Before we go any further, perhaps we could
  18     invite you to introduce yourselves. First Mrs Marr.
  19     Your full name is Susan Jane Marr?
  20   A. Yes.
  21   Q. You are currently the Director for Adult and Children's
  22     Nursing with the ENB?
  23   A. Yes.
  24   Q. Is it right that before that, from 1995 to 1997, you
  25     held the position of Education Officer for Adult Nursing

   1     with the ENB?
   2   A. Yes.
   3   Q. Would you like to tell us briefly what you were doing
   4     before that, from 1992 to 1995?
   5   A. Yes, in 1992 I was Head of Advanced Professional Studies
   6     in Mid-Trent College of Nursing and midwifery, and
   7     subsequently merged with Nottingham University. I was
   8     responsible there for all of the post-qualifying
   9     education for nurses, midwives and health visitors, that
  10     included paediatric programmes.
  11   Q. Prior to that you had been a senior teacher with
  12     responsibility for curriculum design and planning at
  13     Sheffield and North Trent College of Nursing in
  14     midwifery?
  15   A. Yes.
  16   Q. Before that at the Sheffield School of Nursing?
  17   A. That is right.
  18   Q. So you came to the ENB with a long background in
  19     nursing, training, planning and curriculum design?
  20   A. Yes.
  21   Q. Mrs Le Var, if I could invite you to go through the same
  22     process, please. Your current post is that as Director
  23     for Educational Policy, and also Assistant Chief
  24     Executive since 1993 at the ENB; is that right?
  25   MRS LE VAR: Yes.

   1   Q. Before that, what post did you hold?
   2   A. Immediately prior to that I was the director for
   3     continuing education, research and development, and --
   4   Q. That is at the Board?
   5   A. That was also at the Board, for approximately three to
   6     four years, and prior to that, I was also at the Board
   7     as the Professional Adviser for General and Paediatric
   8     Nursing from 1986 to 1990.
   9   Q. So your involvement, direct involvement with the Board,
  10     began in 1986, when you became the Professional Adviser
  11     for General and Paediatric Nursing?
  12   A. Yes.
  13   Q. I think it is right that you mentioned you had been the
  14     Assistant Chief Executive since 1993, and at that time
  15     you were also appointed, were you not, as an executive
  16     member of the Board?
  17   A. Yes.
  18   Q. What do your responsibilities include in that post?
  19   A. As part of the Board members, I have responsibility for
  20     participating in the strategic direction of the Board's
  21     work and ensuring that those objectives are met. In
  22     relation to my own work specifically, I have
  23     responsibility for the major educational policies of the
  24     Board.
  25   Q. Just before we go any further, can I just check that

   1     both witnesses are audible? It may be that Mrs Le Var
   2     you need to speak up a little, if you would be so kind,
   3     and Mrs Marr perhaps the same. Thank you very much.
   4        You are speaking to the statement from Mr Smith
   5     today, and that is obviously concentrated on the area
   6     that the Inquiry was interested in, that of paediatric
   7     and paediatric intensive care, or intensive care
   8     nursing.
   9        Could I ask you, perhaps, just to clear up one
  10     small matter with Mr Smith's statement before we go any
  11     further? If we could have up, please, witness 63,
  12     page 1 on the screen, can I just confirm, is that
  13     visible to both of you and not merely the one? That is
  14     the first page of Mr Smith's statement. If we turn over
  15     to page 5 of the statement, the first paragraph speaks
  16     of the proportion of government grant relating to the
  17     funding of salaries and incidental expenses being
  18     devolved to the regional health authorities in 1992/93
  19     financial year.
  20        That reduced, it says there, the annual Government
  21     grant paid to the Board by approximately 130 million
  22     pounds. That is a correct statement, is it not, of the
  23     reduction in the Board's grant at that time?
  24   A. Yes, that is correct.
  25   Q. What change in the status or the role of the ENB did

   1     that reduction in grant reflect at that time?
   2   MRS LE VAR: Up until that time, the Board had distributed
   3     money from the Department of Health to the institution,
   4     in addition to its main role of approving institutions
   5     in programmes, and in 1993 this financial allocation
   6     went directly to the regional health authorities, so the
   7     Board ceased to distribute the funding. So therefore
   8     the Board was left with the main function of approval of
   9     institutions and programmes.
  10   Q. So it was, as it were, streamlined into purely, and I do
  11     not mean merely, purely a professional quality assurance
  12     organisation, without a role in administering the
  13     management of training courses?
  14   A. Yes.
  15   Q. Then that change in its function is reflected, perhaps,
  16     by page 6 of the witness statement, if we could have
  17     that, please, where, at the top, we see that the
  18     government grant is now approximately something less
  19     than œ7m and that is the sort of order of magnitude of
  20     the Board's grant from the government now?
  21   A. That is correct.
  22   Q. Thank you, Mrs Le Var.
  23        Mr Smith's statement deals with the aims and the
  24     structure of the ENB, and then it moves to dealing with
  25     the role in setting standards for the training of

   1     nurses. In particular, if we look at page 8 of the
   2     statement if we could have that, please, it starts to
   3     set out a history on the structure and content of
   4     training courses which are relevant to paediatric care,
   5     intensive care and paediatric intensive care, and in
   6     particular, it starts by talking of the situation in
   7     1919, when the Nurses Registration Act set up five
   8     registers containing the names of all nurses who
   9     satisfied the conditions of entry to that part of the
  10     register, the SRN qualification, and also
  11     a supplementary part containing the names of nurses
  12     trained in nursing sick children.
  13        In 1923, the abbreviation of RSCN was adopted for
  14     the nurses who sat on or had positions on that part of
  15     the register, the supplementary part of the register.
  16        That is, as it were, the history of the position
  17     of RSCN. Can you tell us a little bit about the status
  18     or the attitude towards people who held that
  19     qualification from that sort of date up towards about
  20     1950/1960?
  21   MRS MARR: I think it is true to say that children's nurses
  22     have had a long struggle in establishing themselves as
  23     a credible discipline within the nursing profession, and
  24     not just simply supplementary to general nursing, or the
  25     SRN as it was then. I think that is as true today,

   1     almost, in that although we have a separate specialist
   2     branch in children's nursing, children's nursing is
   3     still not recognised within the European Union.
   4     Therefore, throughout history, the career prospects for
   5     children's qualified nurses have always been quite
   6     restrictive and remain so today.
   7   Q. So if you were registered at that time on the
   8     supplementary register, as an RSCN, firstly, what would
   9     the numbers of such people be compared to the numbers on
  10     the main part of the register?
  11   A. They would be very small numbers, and that, again, is
  12     the same today; it is a very small branch.
  13   Q. What implications did those facts have for promotion
  14     prospects?
  15   A. In terms of promotion prospects, in many units and
  16     hospitals you were required to have a registered general
  17     nurse qualification before you could progress through to
  18     sometimes Sister level, and certainly managerial levels
  19     within the NHS.
  20   Q. So if one looked, for instance, at the Platt report in
  21     1959, which was a report on the subject of children in
  22     hospitals, children's nursing, which recognised, did it
  23     not, the special position and needs of children within
  24     that setting -- you are nodding but for the sake of the
  25     transcript, can I register that as a yes?

   1   A. Yes.
   2   Q. But nevertheless, it recommended that the Sister who was
   3     in charge of a children's ward should have both an RSCN
   4     and an SRN qualification as it was at that time. Would
   5     that be typical of the attitudes towards the necessity
   6     for having both adult and children's qualifications in
   7     order to achieve promotion?
   8   A. Yes, as far as I am aware.
   9   Q. Was that an attitude that was typical or was expressed
  10     towards children nursing only, or did it reflect other
  11     specialities of the nursing profession?
  12   A. Yes, it was very prevalent as well in the other smaller
  13     disciplines, mental health and learning disability.
  14   Q. Would those again have been smaller disciplines compared
  15     to the general profession of nurses and the numbers who
  16     were obtaining SRN qualifications at that time?
  17   A. Yes. They would have been much smaller.
  18   Q. Mr Smith's statement speaks about the implementation in
  19     1955 of the first combined SRN and RSCN course of
  20     training. I think that course as such ceased in the
  21     1980s, the early 1980s, but was that a pattern of
  22     training that was generally useful for those who wanted
  23     to specialise in children's nursing?
  24   A. Yes, but I think even so, the major route was still
  25     through the registered general nurse programme, and then

   1     as a post-qualifying programme after.
   2   Q. So the general route into children's nursing would have
   3     been to qualify first as an SRN initially, as it was
   4     then called?
   5   A. Yes.
   6   Q. Or an RCN later, and then to add on that as
   7     a post-registration further qualification, the further
   8     training that would lead to a position -- an entitlement
   9     to be registered as an RSCN?
  10   A. Yes.
  11   Q. Can you tell us how long those two parts of that
  12     particular training programme would have taken a nurse?
  13   A. The two parts of the combined?
  14   Q. Yes.
  15   A. The combined course varied across the country from
  16     a minimum of 3 years 4 months to 3 years 9 months, and,
  17     again, the courses in their structure could vary,
  18     depending upon where they were delivered. On the one
  19     hand you could have a totally integrated adult and
  20     children's programme throughout the whole length of the
  21     course, or, in some areas, there was a commencement with
  22     paediatrics and then the middle, perhaps 9 months to
  23     a year, was adults, and then finishing off with
  24     children's experience and further theory at the end of
  25     the programme.

   1   Q. How many courses would have led directly, as a form of
   2     direct entry towards the qualification of RSCN and how
   3     many of them would have been seen as combined with the
   4     option of adding on the RSCN qualification at a later
   5     stage?
   6   A. I am sorry, with the combined programme --
   7   Q. I am trying to get an impression from you, if I may, of
   8     the extent to which people entered the profession in
   9     order to become children's nurses as a direct entry, or
  10     whether or not they tended to qualify first as adult
  11     nurses and then add on the later qualification, that of
  12     children's nurse?
  13   A. The combined programme at the end of that course of
  14     study, the student would be dually registered with both
  15     SRN and RSCN after 3 years 4 months or 3 years 9
  16     months. Then you had the route whereby students
  17     accessed an SRN programme which would have been 3 years
  18     in length, and then the add-on RSCN element would have
  19     been 53 weeks. But they could have had a period of
  20     experience in between, but the minimum would have been
  21     four years. Then you had a direct entry programme which
  22     would have been a 3-year RSCN programme, and as far as
  23     I am aware, there was only one in the country.
  24   Q. So it would have been a rare career choice to qualify as
  25     an RSCN alone?

   1   A. Yes.
   2   Q. And it would have been more common to have obtained or
   3     hope to obtain dual qualifications as SRN and RSCN?
   4   A. Yes.
   5   Q. If we start by talking about the status of children's
   6     nursing and how it was perceived at the beginning of
   7     this period, the start of 1919, I think you commented
   8     that that had changed little now?
   9   A. That is right. Although we have four specialist
  10     branches within pre-registration education, adult mental
  11     health, learning disability and children, the adult
  12     branch is still viewed by many, of course within the
  13     profession and certainly within the European Union, as
  14     still been the generalist nurse. For those on part 15,
  15     the children's branch, the career opportunities,
  16     particularly within Europe, the qualification is not
  17     recognised. But those on part 12, adult nurse, which
  18     should be regarded as a specialism, those nurses could
  19     in fact go into Europe and perhaps care for children.
  20        So there is a huge anomaly there.
  21   Q. Does the ENB have a view on whether that sort of factor,
  22     particularly the question of the EU recognition, has any
  23     impact on the process or the messages, the signals which
  24     are sent out to potential recruits in the field?
  25   A. Yes, because the education officers who are out there in

   1     the field within institutions and practice placements
   2     are coming across situations where students are wishing
   3     to change branches, because they suddenly realise their
   4     career prospects are not as good as the adult branch of
   5     students, because they know if they go on to that
   6     branch, they can more easily undertake a post-qualifying
   7     programme leading to part 15, more so than the other way
   8     round. If they were to qualify as a children's nurse,
   9     getting on to an adult post-qualifying programme is far
  10     more difficult, because there is not the shortage in
  11     that area.
  12   Q. Can you help us a little more on the reasons why
  13     children's nursing might have been perceived as being
  14     a less important or less central discipline within
  15     nursing throughout this entire period?
  16        You have mentioned the fact that it is a smaller
  17     speciality, and that promotion prospects are not as good
  18     if one has the children's qualification only, but there
  19     must be a reason why that situation developed in the
  20     first place.
  21        What is it about attitudes that creates that
  22     situation.
  23   MRS LE VAR: If I try to answer that --
  24   MISS GREY: Could you speak up a little?
  25   A. I think it probably relates to the notion that the

   1     general nurse was considered to be the main nurse, and
   2     that the others were additional qualifications, but that
   3     the general nurse was more or less expected to cope with
   4     most situations.
   5        I think that that is the notion in the background,
   6     and gradually, these other smaller specialties began to
   7     gain importance and credence.
   8        I would add to Jane's statement that the lack of
   9     significance attached to children's nursing in the
  10     1950/60s through to now, I think that there has been
  11     a change in as much as through the Project 2000 and the
  12     children's branch, it is now acknowledged as being
  13     sufficient to meet the requirements for someone to work
  14     in the children's area, but as Jane has described, it is
  15     the career limitations and European directives
  16     limitations that curtail the possibilities for
  17     development in relation to adult nurses.
  18        I do think there has been a shift in perception to
  19     saying that now, for example, for promotion in the
  20     children's area, you would not expect that nurse to have
  21     an adult qualification as well.
  22   Q. But is it fair to say that there might have been an
  23     attitude for some period of time at least that someone
  24     with an adult qualification could still work with
  25     children, whereas someone with a children's

   1     qualification could not necessarily work with adults?
   2   A. That would be a correct assumption to make -- a correct
   3     statement.
   4   Q. I think that that situation existed can be seen in some
   5     of the documents which show that units, for instance,
   6     intensive care units which were managing children, had
   7     an acute shortage of nurses qualified to work with
   8     children, and that therefore nurses trained in adult
   9     nursing were managing both children and adults?
  10   MRS MARR: Yes, that is correct.
  11   MISS GREY: If we could look at one of those documents just
  12     to set the scene for the beginning of 1983/84 when the
  13     Inquiry's terms of reference begin, if I could ask you,
  14     please, to look at file RCPCH 1/1, this is the report of
  15     the British Paediatric Association's Working Party on
  16     intensive care. It is, I am afraid, a difficult
  17     document to look at, because we have only a faxed copy,
  18     so I will have to ask your patience in deciphering it on
  19     the screen.
  20        If we could look at page 6 of that document and
  21     look, if you please, at the table at the top of that
  22     page, so if we could rotate it and then enlarge the
  23     table. It may be that the yellow highlighter will
  24     assist on the column marked "Paediatric training", the
  25     fifth line of figures across.

   1        I think that is probably about as legible as we
   2     can make it, I am afraid. What I wanted to draw your
   3     attention to was a table recording the nursing and
   4     junior staff at intensive care units admitting children,
   5     and you see the columns there are marked firstly "Adults
   6     units, 12 or fewer paediatric patients per annum" and in
   7     the last part of the heading under "Nursing staff" there
   8     is a column marked "Paediatric training", which is the
   9     one that should be highlighted. You may just be able to
  10     see -- I hope you can -- that in adult units which
  11     admitted 12 or fewer paediatric patients per year, the
  12     percentage of staff with paediatric training was 0.8 per
  13     cent.
  14        If we move down to the next column, the adult
  15     units who were admitting more than that number of
  16     paediatric patients per year, there was something
  17     approaching a 1.6 percentage of nursing staff with
  18     paediatric training.
  19        The total for all adult units admitting paediatric
  20     patients was 1.3 per cent of nursing staff with
  21     paediatric training.
  22        If we just turn over the page, please, to
  23     page 7 of that report, if you could rotate the image so
  24     as to show us the lettering rather than the table, and
  25     blow up the first two paragraphs -- I am sorry, could

   1     you take us to page 7, please? Again, could you rotate
   2     it and just show us the first two paragraphs? That, in
   3     text form, is the summary on the table we have just
   4     seen. If you can just read the substantial paragraph
   5     there, the second sentence:
   6        "The units were divided into those which admitted
   7     12 or less children per year and those which admitted
   8     more than 12. Units admitting more than 12 children per
   9     annum tended to be larger and had a closer relationship
  10     with paediatricians, but had only a marginally greater
  11     percentage of trained children's nursing staff, 1.6 per
  12     cent of the nursing establishment, for 6.7 per cent of
  13     admissions."
  14        Can I ask you to comment -- that is not an ENB
  15     document, the British Paediatric Association's report.
  16     Does that paint a picture of the trained nursing staff
  17     for children on intensive care units which would have
  18     admitted children which would have been familiar to the
  19     ENB at that sort of time?
  20   MRS MARR: Yes, it would have been familiar.
  21   Q. Can you describe how the ENB saw the availability of
  22     children's nurses at that time?
  23   A. It is a difficult area to tackle, really, in that those
  24     nurses with a paediatric qualifications, given the
  25     choice, would not have chosen an adult intensive care

   1     unit to work in. We encouraged the staff, through our
   2     practice placement visits and also in approval and
   3     reapproval of programmes, because obviously statistics
   4     such as these and other reports that were available at
   5     the time should have been incorporated within the
   6     curriculum documentation.
   7        We knew there was a problem, and what the ENB were
   8     able to do was to ensure that these statistics were
   9     taken account of, key national policies, and then,
  10     working with educational institutions, to try to enable
  11     non-qualifying children's nurses to gain the appropriate
  12     qualifications.
  13        However, the difficulty there, even with making
  14     programmes more flexible, and acknowledging prior
  15     learning and experience, managers were reluctant to
  16     second practitioners from these adult units because,
  17     upon gaining the children's qualification, many of them
  18     did not wish to return to the adult setting, so they saw
  19     it as a waste of money.
  20   Q. You have touched on a number of themes, including
  21     secondment there, and also flexible courses, to which we
  22     will return. Can I ask you, when you say that
  23     institutions were encouraged to take account of these
  24     documents such as the BPA report, it is only
  25     illustrative, what did you mean by that?

   1   A. To ensure that resources were made available,
   2     particularly -- because the ENB has a specific remit for
   3     education, the controls that we had were in relation to
   4     the education programmes and support of students during
   5     practice placement experiences. What we could make
   6     a condition of was that resources would be made
   7     available and units would work towards establishing an
   8     appropriately qualified workforce to supervise the
   9     students.
  10   Q. When you say "make a condition" you mean in return for
  11     accreditation as a training institution?
  12   A. Yes. They would have had to, and where the staffing
  13     levelling were not appropriate in terms of
  14     qualification, then eventually the ENB would make
  15     a statement that no students undergoing
  16     children-specific programmes could be allowed on that
  17     particular ward or unit.
  18   Q. So if we can pick up a couple of themes there, what we
  19     have is a position where children's nursing has not been
  20     recognised as being an equivalent qualification to adult
  21     nursing, historically, and perhaps because of that, but
  22     also perhaps because of other factors, there has been
  23     a shortage of trained children's nurses, and those
  24     trained children's nurses that did exist would not of
  25     choice choose to work on an adult intensive care unit,

   1     for instance, because they would prefer the environment
   2     that was more fitted for their skills, perhaps, that of
   3     a paediatric setting.
   4        Is that a fair summary?
   5   A. Yes, it is a fair summary.
   6   Q. If we could go back to the history of the development of
   7     the ENB courses that were in part a response to this
   8     situation, Mr Smith's statement, please, witness 63/8.
   9        Mr Smith was there setting out the history of the
  10     Nurses Registration Act and the adoption of the
  11     abbreviation RSCN in 1923. He mentions there was also
  12     enrolment of nurses. Can you tell us more about the
  13     status and importance of the position of the enrolled
  14     nurse, as it then was called?
  15   MRS LE VAR: The enrolled nurse later became involved as
  16     a second level nurse. I think that title describes
  17     their position fairly well. They were part of the
  18     workforce. They were recognised as qualified nurses,
  19     but their role was more limited to direct care-giving
  20     rather than managing other nurses, or managing a large
  21     workload on their own. They were assisting the
  22     registered nurse.
  23        They had not been prepared to be in charge or to
  24     instruct others, or to take on the wider
  25     responsibilities.

   1   Q. If we turn the clock forward slightly to 1983 when they
   2     were first described as "second level nurses", what
   3     would have been the training programme for such nurses
   4     compared to those who were first level nurses?
   5   A. It was a 2-year programme, as opposed to a 3-year
   6     programme in length and the content was considerably
   7     narrower and very skills-focused to giving direct care,
   8     but without the broader theoretical underpinning.
   9   Q. I think it is right that there have been considerable
  10     efforts made by the ENB to make sure that there were
  11     opportunities for enrolled nurses or second level nurses
  12     to convert or to upgrade themselves, one might say, to
  13     first level nursing care. I think if we look at
  14     page 731 of this witness statement, we should have there
  15     the beginnings of a circular that deals with this
  16     particular point.
  17        Is that right?
  18   A. Yes, that is right.
  19   Q. That is a circular dated 1987. Can you just tell us
  20     a little about the background to that particular
  21     initiative, and the reason why that was thought to be
  22     important?
  23   A. There was a major drive by the Board at that time to
  24     provide opportunities for enrolled nurses to convert to
  25     first level and there was a whole range of programme

   1     guidelines that were prepared, and this particular one
   2     is one of them. The Board's intention was in every way
   3     to facilitate converting to level 1 for all of those who
   4     had the ability and wished to convert to first level.
   5   Q. Was that in response to a perception of shortage of
   6     nursing skills, or was that a more general initiative or
   7     desire on the part of the Board?
   8   A. First of all it was in response to a more general desire
   9     by the Board as a result of decisions that there would
  10     be only one level of nurse. The Board felt
  11     responsibility for making additional opportunities
  12     available for second level nurses to convert, and this
  13     particular conversion was for a fairly small group of
  14     involved nurses who had undertaken this course 426
  15     paediatric nursing for enrolled nurses, so it was
  16     a specific conversion programme for that small group of
  17     nurses.
  18   Q. Did skill shortages play any part in this particular
  19     desire, or not?
  20   A. I think skill shortages were part of the total picture.
  21     The Board was aware, all along, of the continuing lack
  22     of children's nurses, and had many a debate about the
  23     difference between the ideal and the pragmatic in order
  24     to try to increase the number. If you did not accept
  25     situations which were less than the absolute ideal, you

   1     could not have progressed to try to increase the number
   2     of nurses in paediatrics.
   3   Q. So it was important, was it then, to widen the entry
   4     routes into paediatric nursing, so as to take advantage
   5     of the potential candidates who might already have some
   6     involvement in nursing?
   7   A. Yes.
   8   Q. What were the funding arrangements made for first level
   9     nurses, who might want to take advantage of
  10     opportunities such as this?
  11   A. If I answer more generally, first of all, it was
  12     recognised as an area of need so that employers,
  13     particularly throughout the second half of the 1980s,
  14     were disposed to enabling this conversion. It was
  15     through employer funding that conversion took place. Of
  16     course, the development has continued since that time,
  17     and there are changes in the funding arrangements and
  18     more of the individual also being party to that, but
  19     Jane may wish to comment on particularly paediatric
  20     funding.
  21   Q. If we stick for the moment to addressing the question of
  22     the second level nurse conversion, if you would like to
  23     make any comment on funding for that, we will come back
  24     to more general issues of funding later.
  25   MRS MARR: No, I do not have anything to add to the funding

   1     issues.
   2   MISS GREY: The process of conversion and upgrading of
   3     skills we have seen, this circular being an example of
   4     that, was designed to be an opportunity for second level
   5     nurses to upgrade their skills.
   6        What is the continuing importance of that
   7     substrata, as it were, of nurses within the NHS? Are
   8     they still a presence, or have they all now converted to
   9     first level nurses?
  10   A. Many thousands have converted to first level, but we are
  11     aware of the piece of work that the UKCC undertook that
  12     was published last year, that there are still many more
  13     out there. Whether they wish to convert or have the
  14     ability to convert, that is another issue. But there
  15     are instances of the second level nurses who have been
  16     out of nursing for several years, perhaps had a family,
  17     perhaps been working in an entirely different sphere,
  18     who are suddenly beginning to realise that this may be
  19     their last chance to return to a particular area of
  20     nursing.
  21        So, yes, there are many more out there.
  22   Q. If we focus in for a moment on an ICU ward, is it likely
  23     that second level nurses would form a part or
  24     a significant part of the workforce on such a ward?
  25   A. They may form a part, but it certainly would not be

   1     a significant part, because of the highly technical
   2     nature and the care requirements within that particular
   3     environment.
   4   Q. If they form any part at all, are they likely to do so
   5     on the basis purely of their general training, or is it
   6     possible that further qualifications may be needed?
   7   A. Many of them who had been working in intensive care may
   8     well have undertaken an ENB post-qualifying clinical
   9     course. I am aware that previous to 1993, there were
  10     specific second level post-qualifying clinical courses,
  11     but from that date, the opportunities were made equal
  12     and the second level post-qualifying courses
  13     disappeared.
  14        So we do know that there are some enrolled nurses
  15     working in intensive care with a first level
  16     post-qualifying clinical course.
  17        Does that make sense? It is quite complex.
  18   Q. It does, thank you. Equally well, there may be some who
  19     have not had any further post-registration,
  20     post-qualification training, and who therefore may be
  21     restricted in the skills that they can bring to bear or
  22     the role they can be expected to play in that
  23     environment?
  24   A. Yes. That could be true, but with the in-service
  25     training and quite sophisticated educational programmes

   1     that some of these units run in-house, it would be
   2     doubtful that any second level nurse would have had no
   3     further education and training within these areas.
   4   Q. Has there been any concern, throughout the NHS, during
   5     again the period from 1984 to 1995, about the use being
   6     made of second level nurses throughout the service, the
   7     demands that are placed upon them?
   8   A. It varies very much across the country. Some units and
   9     hospitals would have been very careful to ensure that
  10     these second level nurses worked within the parameters
  11     of their qualifications, and as Rita said earlier, they
  12     were very much involved in the delivery of direct care;
  13     they were not expected to assess or evaluate the care;
  14     they were very much working to the first level nurse.
  15        But we are aware of areas where the second-level
  16     nurses were "misused", I think is the term that was used
  17     within the NHS, and quite often took charge of a ward.
  18        This may have been with additional in-service
  19     training, so that if questioned, the second-level nurse
  20     would say that they were competent to do this particular
  21     role, because ... but as well, we are aware of
  22     situations where perhaps the second-level nurse was not
  23     aware of her own competencies or the parameters of the
  24     role.
  25   Q. Thank you. If we could go back, please, to witness 63,

   1     page 8, I was asking you about enrolled nurses as it
   2     arose on Mr Smith's statement, where we saw, in the
   3     paragraph a little way down, the very short statement
   4     that there was also enrolment of nurses.
   5        Mr Smith picked that statement up later on, when
   6     he spoke of the changes in 1983, the last paragraph on
   7     the screen, where he mentioned the development that the
   8     enrolled nurses were described as second-level nurses
   9     from 1983 onwards.
  10        However, he talks there of the changes to the
  11     register in 1983 and the production of new training
  12     rules and competencies.
  13        If we could go over the page, please, to page 9 of
  14     the statement, he speaks there of the development in
  15     1985 of new guidelines for the course in sick children's
  16     nursing. If we could just have those up on the screen,
  17     please, they are to be found at page 727.
  18        That is the first part of that particular
  19     circular, which sets out what one might call the
  20     philosophy behind those changes to the rules. Can you
  21     just tell us a little about the reason why these
  22     particular rules were thought to be necessary at that
  23     time?
  24   MRS LE VAR: If I just clarify, the rules came out in 1983.
  25     This was as a result of the 1979 Nurses, Midwives and

   1     Health Visitors Act having set up the new bodies.
   2   Q. You are absolutely right. I used the word "rules".
   3     I think by "rules" you are referring to the statutory
   4     instrument. I should have been referring to
   5     "guidelines", which is what this document is. Thank
   6     you.
   7   MRS MARR: Previous to this circular, we had the General
   8     Nursing Council syllabus for the RSCN qualification,
   9     part 8 came in in 1983. It was felt at the time, within
  10     the Board, that the syllabus needed to be reviewed, not
  11     a major review, because at this time Project 2000 was
  12     looming on the horizon, so it was very much taking the
  13     original GMC syllabus and reviewing it in terms of
  14     contemporary practice, and writing guidelines,
  15     curriculum guidelines. So there was a very definite
  16     shift from the syllabi into general curricula guidelines
  17     at this time.
  18   Q. What sort of emphasis was it thought these guidelines
  19     could give that the previous 1979 syllabus had not?
  20   A. It was very much more emphasis on family-centred care,
  21     and the children's nurse involved in ensuring that the
  22     quality of life for the family, and in particular the
  23     child, was maintained in whichever environment they were
  24     being cared for. I think there was a move at this
  25     particular time to bring into the curriculum nursing

   1     theories, nursing models and an emphasis on the
   2     behavioural sciences, because previously there was
   3     a much greater emphasis on anatomy, physiology,
   4     patho-physiology and the nurse's role within a medically
   5     dominant care setting.
   6   Q. So that changing philosophy, if I may call it that, is
   7     reflected, is it, in the first paragraph that we are
   8     looking at on the screen? If we could just scroll it up
   9     a little, you see there about halfway through the
  10     sentence:
  11        "However, there are major and important
  12     differences between providing nursing care for children
  13     and for adults.
  14        "Children are children before they are patients
  15     and their care must be provided within an appropriate
  16     environment and in a suitable style; secondly,
  17     ill-health and or separation from home may adversely
  18     affect growth and development."
  19        Was that something that was better reflected in
  20     that training syllabus and guidelines than had been
  21     previously the case?
  22   A. Yes, it was emphasised much more in the new programme.
  23   Q. Just turning for a moment towards intensive care, can
  24     I ask you what exposure would trainees for the position
  25     of registration as RSCN or registration part 8 of the

   1     register have had, firstly, to high dependency care
   2     throughout the course of their training?
   3   A. All the students would have had experience within a high
   4     dependency care setting, or, caring for children
   5     requiring high dependency care, because that could have
   6     been in an area not designated as high dependency.
   7   Q. What about intensive care: would there have been any
   8     exposure to that?
   9   A. There may have been exposure for some students in some
  10     areas, but it was certainly not seen as an essential
  11     component of pre-registration programmes.
  12   Q. That was something, was it, that was dealt by
  13     post-registration, more specialised courses, if it was
  14     to be dealt with at all?
  15   A. Yes, that is correct.
  16   Q. If we could go, please, to page 739 of the witness
  17     statement. This is the title page of the guidelines for
  18     a shortened course for registered, RGN nurses with
  19     experience in paediatric nursing leading to admission to
  20     part 8 of the register as an RCN.
  21        Can you tell us a little bit about the background
  22     to that document and the reason why it was thought that
  23     was a useful approach to be adopted? If it would help,
  24     the next page, we should perhaps look at page 740, which
  25     gives us a little more detail on the nature of the

   1     course. If we can just see the whole of the purpose of
   2     the course.
   3   A. This programme was set up because we knew that within
   4     children's care areas there were a number of Registered
   5     General Nurses who had worked there for many years and
   6     who could perhaps achieve the outcomes of what was then
   7     the 53-week programme, in a shorter space of time.
   8        If I could just explain that a little more fully,
   9     if you had a student who had completed their first
  10     registration, say as a Registered General Nurse, they
  11     could then go straight on to the 53-week RSCN course
  12     with absolutely no experience of caring for children
  13     post-qualifying.
  14        Then, within that same cohort undertaking the
  15     53-week course, you would get students who had been in
  16     these care areas for many years and had a lot of
  17     experience.
  18        So in effect, you would have two groups of
  19     students with very different learning needs. So this
  20     was introduced.
  21   Q. You say that was an attempt to respond to that by
  22     shortening the requirements for those who had already
  23     built up relevant practical experience?
  24   A. That is right, yes.
  25   Q. This particular training course required a minimum of

   1     three years full-time, or equivalent part-time
   2     experience in a position of responsibility providing
   3     direct care for sick children?
   4   A. Yes.
   5   Q. Was there any discussion or debate over the length of
   6     the pre-registration experience required before you were
   7     allowed to be admitted on to this course?
   8   A. The pre-registration experience would have been three
   9     years.
  10   Q. What I was trying to explore with you was whether or not
  11     there was any debate as to whether or not three years
  12     was too much, or whether it was taken as being the
  13     necessary minimum before you could be eligible to be
  14     admitted to this course?
  15   MRS LE VAR: There was discussion at the time, and the time
  16     limit set on it is not research based and that was
  17     acknowledged because no-one knows whether it takes 2 and
  18     a half or 3 years or 3 and a half years, but it was set
  19     on as the sort of length of time that people felt, as
  20     the body that had to make the decision, as being an
  21     appropriate amount of time.
  22        Subsequently, there have been views that it may
  23     not necessarily have to be that amount of time, but no
  24     formal change has come about.
  25   Q. So the requirement is still in effect as it is in that

   1     document, although obviously the routes in have changed
   2     since Project 2000?
   3   A. Yes. Could I introduce one other factor about this
   4     particular page? It is in the middle paragraph which
   5     talks about the rule 18(1). That is also a major change
   6     that happens in the programmes in 1983. They have to
   7     meet those competencies which were in the statutory
   8     instrument and that was a major change in the 1979
   9     syllabus, so that the outcomes were stated in the
  10     statutory instrument in the terms of competencies.
  11   Q. Why was that thought to be important?
  12   A. The change and the importance of it was that previously
  13     the syllabus contained a list of content, but it did not
  14     specify what the outcomes should be in terms of
  15     competencies and this was the first time, when in
  16     nursing education, outcomes were stated in terms of
  17     competencies with considerable debate proceeding the
  18     definition of the term "competency".
  19   Q. So if we could just explore that a little bit further,
  20     what would be the competency that an RSCN was expected
  21     to achieve by the end of their one-year
  22     post-qualification training period, if they have already
  23     been registered as an RGN? It may help, perhaps, if we
  24     look at page 50 of this witness statement.
  25        This is the ENB course approval process, the

   1     rules, regulations and guidelines. It is issued in
   2     1987. That is just the cover sheet. I wanted to give
   3     you an anchor on the document. If we could just turn
   4     over the page, please, to page 51, there again, just to
   5     give you an anchor on what this document is, there is
   6     the actual content of the document set out in the title
   7     page.
   8        If we could now go, please, to page 64, this is
   9     the statement of the competencies to be achieved at the
  10     completion of the training course for, amongst others,
  11     part 8.
  12        Is that then the definition of the outcomes that
  13     were to be achieved by nurses after following these
  14     training courses?
  15   A. Yes.
  16   Q. We can perhaps scroll through it. It sets out general
  17     requirements for appropriate patient care, and then, at
  18     the bottom of the list, (a) to (i), it says "These
  19     outcomes should be related to the care of the particular
  20     type of patient with whom she is likely to come into
  21     contact when registered in that part of the register for
  22     which the student intends to qualify."
  23        So these would then be tailored, would they, as to
  24     whether or not you wanted to register on part 8 of the
  25     register?

   1   A. Yes.
   2   Q. What would be the particular focus if you wanted to
   3     register as a part 8 RSCN in what would be the special
   4     elements of that type of training?
   5   MRS MARR: The special elements would be very much, as
   6     I said earlier, the family-centred approach to care,
   7     recognising that the child has unique care needs and
   8     that they are very different to the adult, and
   9     recognising as well that the child has developmental
  10     needs as well as the physical, social and psychological
  11     care needs, the developmental aspects and the psychology
  12     of being in hospital would be very much emphasised.
  13     Also, the skills of assessment when you may be caring
  14     for a child who has not yet developed speech or is
  15     unable to tell you what is wrong with them, knowing how
  16     children respond to pain and illness and separation.
  17        Also, among the assessments, very sophisticated
  18     skills of observation would be emphasised within the
  19     programme.
  20   Q. Because assessment and observation of children who
  21     cannot communicate may put particular demands on a nurse
  22     that adult nursing would not do; is that right?
  23   A. That is right. Just as an example, when we had students
  24     who undertook a combined programme leading to the dual
  25     registration, we would often have managers in the adult

   1     care units wanting these nurses, because of their
   2     exceptional skills in assessment and observation, and
   3     that again was a drain for the children's nursing,
   4     because they were poached into the adult areas. I think
   5     that highlights how valuable these nurses were, within
   6     the profession.
   7   Q. We were talking before of the routes into qualifications
   8     and RSCN, and firstly, the shortened route, if you had
   9     already acquired relevant paediatric nursing
  10     experience. Could I just take you briefly to page 734,
  11     to develop that point a little further? If you can read
  12     the screen there, that is the start again of guidelines
  13     for a part-time course for mature Registered General
  14     Nurses, leading again to admission to part 8 as an RSCN
  15     and if we turn over the page, please, to page 735, that
  16     describes the Board's concern about the lack in
  17     paediatric units of sufficient numbers of RCNs, and it
  18     describes this document as being part of an attempt to
  19     help remedy the situation and to provide opportunities
  20     for mature RCNs to convert or to further their
  21     qualifications, as RSCNs.
  22        Could you just help us on the general background,
  23     which is already implicit in the document, which led to
  24     the production of this training course?
  25   MRS LE VAR: At that time in particular, and still to

   1     a large extent today, the pre-registration education
   2     programmes were all full-time, so this was a development
   3     to highlight the potential for part-time programmes. It
   4     will be particularly suitable for those who were already
   5     employed in the paediatric area, so that through
   6     continuing employment and combining that with education
   7     and training, they would be enabled to become children's
   8     nurses.
   9        Now it is more widely recognised that part-time
  10     facility is totally available, but it is still not
  11     really being taken up.
  12   Q. Why has it not really been taken up? Are there any
  13     particular reasons you can highlight?
  14   MRS MARR: Off the top of my head --
  15   Q. If it is something you need to return to --
  16   A. I could return to that and get the further information.
  17   Q. Would it be fair to say at the moment it is difficult to
  18     comment on the extent to which that proved to be
  19     a useful training route, or the reasons why, if it was
  20     not, there were obstacles?
  21   MRS LE VAR: I could comment on one aspect of it. It would
  22     seem to be linked with integration into higher education
  23     and the academic year and the funding per academic year,
  24     that probably has some relationship with it.
  25   Q. Did it have anything to do with the attitudes of

   1     employers towards part-time release for training
   2     programmes?
   3   A. Not specifically for part-time release, it is just
   4     generally difficulties of release and difficulties of
   5     funding.
   6   Q. So difficulties that would be common both to full-time
   7     and to part-time courses.
   8        That document speaks of the concern of a lack of
   9     RSCN experience in paediatric units. Can you just tell
  10     us, you mentioned a minute ago the fact of shortages at
  11     that time. What documents or studies were highlighting
  12     or were causing concern, leading to concerns being
  13     expressed at that time over the availability of RSCNs,
  14     or, perhaps to put it a better way, what was the ENB's
  15     appreciation of the situation regarding the availability
  16     of skilled children's nursing.
  17   MRS MARR: During the time ...
  18   MISS GREY: During the late 1980s?
  19   MRS MARR: I think there was a move nationally to increase
  20     the funding for post-qualifying programmes leading to
  21     either part 8 or to part 15, and many more students went
  22     through these programmes, so the situation would have
  23     improved over this period of time.
  24        Then there was the move to encourage more students
  25     to access the 53-week programme, or 52-week on to part

   1     15, but because out there, within the workforce, you
   2     have, on the one hand practitioners with a lot of
   3     experience and the need to get more students through the
   4     programmes, so there would still seem to be the need for
   5     the shorter 26-week programme. But there was
   6     a difficulty with the contemporary care being far more
   7     sophisticated; there had been advances in technology and
   8     advances in nursing, in medicine, in pharmacology,
   9     within the profession itself it is felt that the minimum
  10     of diploma level should be the level at which these
  11     programmes are actually pitched.
  12        But out there in the field, there are still
  13     a number of practitioners who qualified through a route
  14     that was not recognised in terms of an academic level,
  15     and are fearful of entering a University to undertake
  16     what is often perceived as a very academic programme.
  17   Q. So you are describing now difficulties in encouraging
  18     people to enter within the post-Project 2000 framework,
  19     when nursing became a University led subject?
  20   A. Yes.
  21   Q. But pushing it back towards the late 1980s, we have
  22     described a general problem about the availability of
  23     trained children's nurses, and the ENB would have been
  24     aware of that situation at the time, receiving figures
  25     or information?

   1   A. Yes.
   2   Q. Are you able to help us on whether or not that shortage
   3     was varied from different parts of the country to
   4     others?
   5   A. Again, I do not have the statistics, but -- I mean, we
   6     could certainly get them for you.
   7   Q. Thank you. I think perhaps we will leave it at the
   8     moment, then?
   9   A. Certainly in rural areas there would have been more of
  10     a problem, because the geography often means that
  11     students are not able to access programmes because of
  12     life commitments.
  13   MRS LE VAR: There was a general shortage. That was
  14     certainly known and the Board was very aware of this.
  15     The Board had an adult and children's nursing committee
  16     and had members of the committee who were leading
  17     children's nurses in the country, so the committee would
  18     have been aware of the general shortage and any specific
  19     areas.
  20        In overall terms, the Board, throughout the 1980s,
  21     was influential in causing additional funding to be made
  22     available when it was necessary for programmes to
  23     continue to have accreditation, so this was quite
  24     significant. I think that some of this would have been
  25     reflected in relation to children's nursing programmes

   1     as well, but as we have mentioned early on, there
   2     continued to be the overall problem that we were
   3     against, that you needed to have sufficient children's
   4     nurses in the training areas in order to be able to take
   5     increasing numbers of students, and this was the
   6     continuous struggle.
   7        I think later on, into the 1990s, it was picked
   8     more as an issue by workforce planners and funders in
   9     a more realistic way.
  10   Q. Thank you. I have been asking you questions for about
  11     an hour and a quarter or so, and it may be that this is
  12     an appropriate moment for a break. I think you
  13     indicated in advance that you would prefer to press on
  14     as much as possible, so I do not know whether that would
  15     have any influence over the timing of any potential
  16     break.
  17        Chairman, I am really in your hands as to what you
  18     would like to do.
  19   THE CHAIRMAN: We would prefer, and I looked at the
  20     stenographer for her indulgence, we would prefer to
  21     press on, if we could, at least for another half an
  22     hour. Is that acceptable?
  23   MRS MARR: That will be fine.
  24   MISS GREY: We have spoken or gone through many of the
  25     training courses that the ENB was accrediting for, the

   1     RSCN in particular, the training routes for that
   2     qualification. Can you help us a little on the progress
   3     of training institutions for that qualification and the
   4     sort of scrutiny that the ENB applied in order to ensure
   5     that those training courses were properly done.
   6   MRS LE VAR: The Board fairly early on developed a common
   7     set of requirements, regulations and guidelines, for the
   8     approval process, so this applied to nursing, midwifery
   9     and health-visiting programmes. It consisted of the
  10     institution meeting to make contact with the Board, with
  11     the Education Officer, and submitting an approval in
  12     principle document, and if this was accepted, then they
  13     would prepare a more comprehensive submission document
  14     to meet the Board's requirements and criteria.
  15        This submission document would be perused by the
  16     Education Officer and it might then be looked at by the
  17     particular committee, or there might be a panel visit.
  18     The Panel would consist of committee members, possibly
  19     Board members and the relevant Education Officer, or
  20     more, depending on the specialty and the particular
  21     needs.
  22        So essentially, it was a perusal of the
  23     documentation together with a visit which then led to
  24     approval or otherwise of the education programme.
  25   Q. That makes it sound like a visit from the centre. Was

   1     there also a system of regional networking or links with
   2     training institutions?
   3   MRS MARR: Yes. Within the English National Board, we have
   4     the four local offices, one in London, one in Bristol,
   5     one in Chester and one in York, and within each of the
   6     local offices, there is a team of education officers
   7     representing the different disciplines within nursing,
   8     plus midwifery.
   9        So each of those education officers has
  10     a designated higher education institution, as they are
  11     now, and that person maintains the link with that
  12     institution for all programme approvals, reapprovals,
  13     and most recently, with the Board's standards, annual
  14     monitoring and review, and also practice placement
  15     visits.
  16   Q. So would that be a means of picking up if necessary any
  17     concerns or problems, or initiatives that a training
  18     institution wanted to bring into play?
  19   A. Yes, it would. It is an excellent network for picking
  20     up issues, both from the educational institutions
  21     themselves, but also we do link very closely with the
  22     regional offices, and particularly the education lead
  23     within the regional office and also --
  24   Q. Can I stop you there when you say "the regional
  25     offices", you are referring to the Regional Health

   1     Authorities?
   2   A. Yes, and each of those has an education lead, and we
   3     network with those Regional Health Authority offices and
   4     also now with the education consortia across the
   5     country, so we have various ways of picking up issues.
   6   Q. You have put that answer in the present tense. Would it
   7     also be true that that network, and forms of links,
   8     existed throughout the period from 1984 onwards?
   9   A. Yes, it would, but obviously not with the consortia,
  10     because they are only just newly established. But, yes,
  11     those networks would have existed.
  12   Q. What about formal re-accreditation or revalidation for
  13     training courses. How does that work?
  14   A. That would occur every five years, if they had the full
  15     five years approval, but at the initial approval of
  16     a programme, the Panel could impose conditions that had
  17     to be met prior to the commencement of the course or if
  18     it was a condition towards the latter end of the course,
  19     we could let them start the programme, but then we would
  20     go back and ensure that this condition was met by giving
  21     them time.
  22   Q. Those sorts of conditions might, for instance, include
  23     requirements about staffing levels, supervision for
  24     practical placements of trainees, perhaps; could that be
  25     an example?

   1   A. It could be an example, but the programme would not
   2     commence until we had some firm commitment that change
   3     would occur. For example, with the issue of
   4     appropriately qualified practitioners to support
   5     students, if there was a query perhaps in the third year
   6     of the programme, we would, as Board officers, very
   7     carefully scrutinise on an annual basis how this
   8     development was shaping up.
   9   Q. If I could take you, then, just more concretely to some
  10     of the documents reflecting those issues of supervision,
  11     if we could look, please, at page 26 of the witness
  12     statement, that is the first page, the title page, if we
  13     could just scroll down, please, the 1985 guidelines, the
  14     content would be more apparent if we turn to page 33.
  15     This is the information required from training
  16     institutions wishing to make submissions for course
  17     approval. In particular, at 5.3, the relevant paragraph
  18     is noted there:
  19        "Methods of maintaining links with clinical
  20     practical placements in health services and other
  21     relevant locations."
  22        If one goes to page 38, paragraph 5.3 sets out the
  23     requirement on any training institution to specify the
  24     liaison methods and also the details of any practical
  25     placement that students were required to go on.

   1        If I could then take you through also to page 43,
   2     to the bottom two paragraphs, please, "Practical
   3     experience": there again, the requirements placed upon
   4     the would-be training institution to specify the nature
   5     of the practical experience and the training profile or
   6     the staff that would be supervising it.
   7        What was, in general, the degree of scrutiny
   8     required of nurses who were training for the position of
   9     RSCN on these practical placements?
  10   MRS MARR: There would have been a great deal of scrutiny,
  11     and prior to 1985, the education officers within the
  12     Board and prior to that, the General Medical Council
  13     inspectors, were responsible for undertaking the audit
  14     of practice placements themselves.
  15        Following 1985, the Board devolved responsibility
  16     down to educational institutions for auditing their own
  17     practice placements, but obviously, a strategy had to be
  18     developed and systems and mechanisms put in place and
  19     agreed with the English National Board.
  20        As a result of the devolvement of this important
  21     activity, the education officers subsequently then
  22     monitor on an annual basis whether the strategy is
  23     working, whether the systems and mechanisms in place are
  24     yielding the appropriate information that enables the
  25     institution to make a decision on whether the placement

   1     continues to be suitable.
   2        Each year the Education Officer will look at
   3     a sample of audit documents, looking at best practice,
   4     those areas that need improvement, and will go out and
   5     personally then audit those placements for themselves,
   6     as a secondary check.
   7   Q. If I could take you, please, to page 121, this is the
   8     title page of a 1988 circular, the institutional course
   9     approval and reapproval process, information required,
  10     criteria and guidelines.
  11        Over the page, page 132, the third
  12     paragraph highlights the most significant addition to
  13     the previous circular relating to "the supervision of
  14     nursing students whilst undertaking practical
  15     experience."
  16        It refers to page 28, item H of the circular,
  17     "confirms that approved training institutions should
  18     demonstrate that they are working towards achieving
  19     a situation whereby, for every 2 nursing students on
  20     duty, there is one appropriately qualified first-level
  21     nurse on duty."
  22        What did the phrase "working towards" represent in
  23     that circular?
  24   A. Working towards, in this context meant that before the
  25     Board would approve a programme of study there needed to

   1     be evidence from the hospital unit where placement
   2     experience was to be provided of exactly what they were
   3     going to do in terms of professional development,
   4     enabling practitioners to gain further qualifications.
   5        It would include the strategy, the funding and the
   6     impact on the service whilst these practitioners were
   7     away and undergoing further training. And also,
   8     a time-scale. Then the Board would very carefully
   9     monitor that the action plan and the timescales were
  10     being adhered to.
  11   Q. To the lay eye, looking at that document, it appears to
  12     suggest that the scrutiny or supervision of trainees on
  13     the nursing ward might fall well short of the desirable
  14     end, that is, the one qualified first-level nurse, and
  15     that really one was having to make do, with the
  16     assistance of a plan to alter that situation in the
  17     future, with staffing levels that were not at least
  18     ideal from the point of view of training of nurses?
  19   A. Where the situation was such that it was felt that it
  20     really is going to compromise the quality of the
  21     educational programme, one of the strategies that
  22     developed in quite a few areas was where the qualified
  23     tutor, nurse tutor, and that could be a qualified nurse
  24     tutor with a paediatric qualification, would team up
  25     with the supervisor in a particular area, and form

   1     a tripartite relationship, so that the support of the
   2     student, advice, guidelines and assessment, was not
   3     compromised.
   4        That was one of the ways in which we addressed the
   5     situation.
   6   Q. When you say you addressed "the situation", what do you
   7     mean by "the situation" in the first place?
   8   A. Where there was not enough appropriately qualified staff
   9     to adequately supervise and support students in
  10     a particular area. If that was the case and there was
  11     another area that we could use, then we would not have
  12     used the other ward in the first place. But the
  13     practice placement situation is quite crucial to the
  14     programme and there are never enough of them, so it is
  15     the sort of "catch 22" situation.
  16   Q. So does it follow from that that there were many
  17     situations, or it was a widespread problem, to discover
  18     that on proposed or possible placements the level of
  19     supervision that you would like to have seen was not yet
  20     available?
  21   A. I would not say it was widespread. It was certainly
  22     a problem in certain areas across the country, but also,
  23     you had the sort of added dimension that you could have
  24     a very committed and motivated first level qualified
  25     nurse with a paediatric qualification who could

   1     supervise perhaps more than two students quite
   2     adequately by virtue of her interest in teaching, years
   3     of experience and being comfortable in that area, as
   4     opposed to somebody who was perhaps not long qualified
   5     and getting to grips with their own professional
   6     practice.
   7        So there were certain variables that we could take
   8     into account, but bearing in mind that the overriding
   9     principle was based on the comment in that document.
  10   Q. You refer just briefly to different areas, different
  11     skill shortages. Could I just take you, please, to
  12     page 737 which is a document dated about the same date?
  13     The last one we saw was July 1988. This is October
  14     1988.
  15        That speaks of the supervision of students gaining
  16     nursing experience in children's wards specifically.
  17     That is the title page. If we turn over the page,
  18     please, 738, there is a comment there:
  19        "The Board has agreed that as from 1995, it will
  20     become a requirement, in children's wards where student
  21     nurses are gaining nursing experience, for the nursing
  22     team to be led and the students supervised by an RSCN at
  23     all times."
  24        That document is October 1988. The requirement is
  25     to be attained finally in 1995. What does that tell us

   1     about the possible difficulties that were being
   2     experienced at the time?
   3   MRS LE VAR: I think it does tell us a great deal. This
   4     work was done by the Children's Nursing Committee within
   5     the Board, and it was acknowledged that with the time
   6     that it takes to prepare additional nurses, you had to
   7     allow that time, and if they were people who were
   8     already general nurses, then they needed to do the
   9     shortened one-year course. Overall, it was felt it was
  10     necessary to have a lead time as long as that to be able
  11     to make the statement that we wanted to have as the
  12     outcome.
  13   Q. Are you able to help us on what, if the ideal or the aim
  14     was not yet being achieved, what the general position
  15     might have been at the time in many of the training
  16     wards for RSCNs?
  17   A. In general terms, it would have been that there were
  18     RSCNs on those wards, because as Jane has said, had that
  19     not been considered to be sufficient, then the areas
  20     would not have been approved for training. It was
  21     always about what is sufficient, what constitutes safety
  22     and acceptable standard of care, as opposed to that
  23     which would have been preferable or eventually ideal.
  24   MISS GREY: Sir, I am conscious of the time as I ask these
  25     questions, and also of the stenographer. I think I have

   1     perhaps another quarter of an hour, 20 minutes or so.
   2     I wonder whether it might be appropriate to break for
   3     10 minutes, given those particular constraints, and then
   4     to press on afterwards, if that is acceptable also to
   5     Mrs Marr and Mrs Le Var.
   6   THE CHAIRMAN: Thank you, Miss Grey. Let us take
   7     15 minutes, then, and reconvene at 5 past 1.
   8   (12.48 pm)
   9               (A short break)
  10   (13.06 pm)
  11   MISS GREY: Mr Chairman, we were dealing before the break
  12     with the question of accreditation for placements.
  13     I wonder if we could ask our witnesses to turn their
  14     eyes directly to the Bristol Royal Infirmary here, and
  15     tell us what their knowledge is of the accreditation of
  16     the wards within that, starting first with the Bristol
  17     Children's Hospital. Are you able to tell us whether or
  18     not the intensive care unit there was recognised as
  19     a training ward for any particular courses during the
  20     period we are concerned with?
  21   MRS MARR: Yes, the Children's Hospital intensive care unit
  22     would have been approved for students undertaking the
  23     paediatric intensive care programme, the ENB 415.
  24   Q. Would that recognition have extended to Ward 5, the
  25     intensive care unit, the cardiothoracic unit at the

   1     Bristol Royal Infirmary which admitted both adults and
   2     children?
   3   A. No, it would not.
   4   Q. Your experience is within the paediatric field. Are you
   5     able to help us on the accreditation for that ward,
   6     Ward 5, for other courses that the ENB may have been
   7     concerned with?
   8   A. Well, I am not able to verify that at the moment, but it
   9     is something we could go into the archives for.
  10   Q. You have spoken about the arrangements for supervising
  11     trainees on placements within the hospital setting.
  12     What would have been the incentive from the hospital's
  13     point of view to allow such trainees to be used within
  14     their wards?
  15   A. In terms of incentives?
  16   Q. Advantages to the hospitals. I am not speaking of
  17     financial incentives directly.
  18   A. In terms of advantages, many hospitals and units see the
  19     advantage of having students as enabling their own staff
  20     to take advantage of the links with schools of nursing
  21     previously and now universities, and they see it as
  22     a way of ensuring that the contemporary care practices
  23     that evolve within a very dynamic healthcare situation
  24     are shared with the University and vice versa. So there
  25     is a sort of reciprocal arrangement where both sides

   1     benefit from working together in a partnership, and
   2     ensuring that the students have the best possible
   3     learning opportunities in the best possible learning
   4     environment.
   5   Q. What about, more bluntly, practical advantages in an NHS
   6     that talks about staffing shortages on many occasions,
   7     if not all the time. What would be the role of trainees
   8     within that context?
   9   A. Prior to Project 2000, the first programmes for which
  10     were approved in 1989, students for pre-registration
  11     programmes went through what was called the
  12     "apprenticeship" system, and, yes, they were counted
  13     within the team numbers and were used -- the phrase in
  14     the NHS is "as pairs of hands."
  15        So, yes, there would have been an advantage in
  16     taking students on, but there again, if you provide
  17     a quality environment with appropriately qualified
  18     staff, that does take longer, so it depends how the
  19     students were used.
  20   Q. That there might be compensating costs, you mean, to the
  21     institution because it has to take on training
  22     obligations which might match or at least count against
  23     the time gained by having additional students; is that
  24     what you mean?
  25   A. Yes.

   1   MRS LE VAR: Ultimately it was seen as generally a positive
   2     thing, so that wards wanted to be training wards because
   3     of the positive effects it had on all of the
   4     environment, and a third effect would be that it tended
   5     to aid recruitment following completion of training to
   6     that particular unit or ward.
   7   Q. So it was seen as an advantage for three reasons:
   8     firstly, that it put you in contact with the higher
   9     education ward and continuing evolution of nursing
  10     skills; secondly, there was an element of a pair of
  11     hands, and thirdly it aided recruitment
  12     post-qualification?
  13   MRS MARR: Yes.
  14   Q. You spoke of that position as being the case before
  15     Project 2000. What difference, if any, did that
  16     development have?
  17   A. With Project 2000 students became supernumerary to the
  18     workforce, which in essence meant that their learning
  19     became paramount and that placements were chosen to
  20     enable the student to meet the outcome of that
  21     particular module or part of the course.
  22        It also meant that the student could be released
  23     from that area to attend study days or to meet up for
  24     a seminar or to follow patients through the different
  25     areas, so if, for example, you had a child who was going

   1     to theatre, then the student was perhaps more able to
   2     follow the child through from the ward to theatre,
   3     perhaps through to intensive care, back to the ward,
   4     where, previously, with the apprenticeship model,
   5     sometimes the students were relied upon more heavily to
   6     provide care in the area.
   7   Q. We have dealt over the last couple of hours with the
   8     question of training as an RSCN, but that is of course
   9     a generalised children's training, nursing
  10     qualification. There would be nothing specifically in
  11     that course relating to training and paediatric
  12     intensive care.
  13        I think it is the case that prior to 1987 there
  14     was no specific post-registration course in paediatric
  15     intensive care; is that correct?
  16   A. That is correct, yes.
  17   Q. The nearest equivalent at that time would have been
  18     ENB 100, an intensive care adults course, and also
  19     ENB 405, special and intensive care of the new-born.
  20     Would that be seen as having any relevance for
  21     paediatric intensive care?
  22   A. It was seen as having some relevance, but there were two
  23     very distinct areas of care. They developed their own
  24     sort of body of knowledge that was specific to each of
  25     them, but there would have been core material that both

   1     could have benefited from in the field of critical
   2     care.
   3   Q. I think that the other area of post-registration
   4     qualifications that would have been relevant to our
   5     Inquiry prior to 1987 was the ENB 160?
   6   A. That is correct, yes.
   7   Q. Can you tell us a little about that?
   8   A. That was a post-qualifying clinical course that was
   9     established through the then joint board of clinical
  10     nursing studies. It was a programme that was between 35
  11     and 39 weeks in length, and it addressed the medical and
  12     surgical cardiothoracic care needs of children.
  13   Q. That was a course that was established prior to 1984,
  14     was it?
  15   A. Yes, it was.
  16   Q. Was it available anywhere within the South West?
  17   A. Not that we are aware of, but again, we could verify
  18     that if necessary.
  19   Q. In 1987 I think a new course was introduced, the
  20     ENB 415?
  21   A. Yes.
  22   Q. What was its title?
  23   A. Intensive Care Nursing for Children.
  24   Q. That arose, did it, from the first children's intensive
  25     care nursing course that had been established in 1986 by

   1     Great Ormond Street?
   2   A. That is correct, yes.
   3   Q. It was validated the following year by the ENB, 1987?
   4   A. Yes.
   5   Q. And then it was followed by other institutions who
   6     applied for validation of their courses?
   7   A. Yes.
   8   Q. Perhaps the existing training courses that some of them
   9     had already been providing for their staff; is that
  10     correct?
  11   A. That is correct, yes.
  12   Q. Is that a course that became available within the South
  13     West?
  14   A. Yes, it did.
  15   Q. At the Bristol Children's Hospital?
  16   A. Yes.
  17   Q. It is right, is it, that it is now still available as
  18     NVQ level 3 as part of the Project 2000 training model
  19     that is now being followed?
  20   A. I am sorry, I am not ...
  21   Q. Let me put that more broadly. Is that course still
  22     available now within the NHS as a training module for
  23     nurses?
  24   A. We are still talking about the 415?
  25   Q. Yes.

   1   A. The 415 currently still runs. It has an academic level
   2     attached to it now, which, across the country, could be
   3     either diploma, or, with the sort of evolvement of the
   4     specialist practitioner recordable qualification, we now
   5     have several paediatric intensive care specialist
   6     practitioner programmes across the country and that is
   7     at degree level.
   8        It still remains as a post-qualifying programme,
   9     so in terms of its interface with Project 2000 or the
  10     DipHE, as it is now called, students would have to
  11     undertake the pre-registration three-year programme in
  12     part 15, and then, if they so wished to work in
  13     paediatric intensive care, they have the option to go on
  14     to the 415, or the S415 which is the specialist
  15     practitioner.
  16        The difference is that the 415 is very much
  17     concentrating on acquiring the knowledge, skills and
  18     expertise to care for children in paediatric intensive
  19     care, the S415, the specialist, is for a minority of
  20     children's nurses who are at the forefront of practice
  21     and wish to have the skills and knowledge of research
  22     and evidence-based practice to take the practice of
  23     paediatric intensive care forward.
  24   Q. When was that course introduced?
  25   A. That course was introduced, the first one was validated

   1     in 1997.
   2   Q. So if we are talking about the period from 1987 when the
   3     ENB 415 was first validated, to 1995, the optimum
   4     qualifications for a nurse working on paediatric
   5     intensive care would be RSCN followed by 415; is that
   6     correct?
   7   A. That is correct, yes.
   8   Q. We have touched briefly upon the developments of
   9     Project 2000 throughout the course of your evidence.
  10     Can you just tell us briefly whether the introduction of
  11     that course had any impact or change, or made any change
  12     to the status and importance of children's nursing?
  13   A. The impact that it had on children's nursing was the
  14     fact that it was recognised as a specialism in its own
  15     right and it was designated a separate part of the
  16     register, part 15.
  17        The other impact that the development had, not
  18     just for children's nurses but for all nurses
  19     undertaking this programme, was the emphasis on --
  20     particularly at the beginning of the programme --
  21     health, it was a health-based curriculum, and far more
  22     emphasis was placed on the knowledge base of nursing,
  23     and the whole thrust behind Project 2000 was to develop
  24     a "knowledgeable doer".
  25        Previous to that, I think nursing was very much

   1     viewed as doing without the underpinning knowledge to
   2     support decision-making, so the impact on care would be
   3     students who had the broad base of knowledge to support
   4     the nursing practice, and the clinical skills and also
   5     skills of critical analysis, questioning, far more
   6     emphasis on research, evidence-based practice, and
   7     lifelong learning was really sort of coming into its own
   8     there, whereby it was felt that you could not fit
   9     everything into a pre-registration programme that would
  10     equip the practitioner with knowledge and skills for
  11     life. And therefore, there was a greater emphasis on
  12     continuing professional development on qualifying.
  13   Q. That is something which has been picked up and further
  14     developed in recent years; is that right?
  15   A. Yes.
  16   Q. Mr Smith's statement gives us details of those
  17     particular developments.
  18   MRS LE VAR: I would like to add, it also enabled direct
  19     entry, as it were, into becoming a children's nurse, so
  20     that no longer were you expected to become an adult
  21     nurse, a general nurse, but it was the three-year
  22     training, so that makes things more straightforward.
  23        Two other matters that I would like to point out
  24     are that this programme then changed the focus as Jane
  25     has described, but it then led to outcomes rather than

   1     competencies and the significance of that was meant to
   2     be a broader expression of theoretical underpinning and
   3     broader understanding of the term "competency" in a way,
   4     and one further point that is emphasised in those
   5     programmes is the accountability which is stated in the
   6     statutory instrument, so there is a considerable
   7     emphasis on the accountability of the qualifying nurse.
   8   Q. To whom?
   9   A. Account for one's own actions and one's own care for
  10     one's own decision. That is the meaning of that term.
  11     Clearly it is within the team, too.
  12   Q. So it is part of the same theme that turned nursing
  13     education into higher education to emphasise the status
  14     of the nurse as an autonomous professional who makes her
  15     own decisions and is accountable both for those
  16     decisions but also for the process of her continuing
  17     education?
  18   A. Yes.
  19   Q. Just to go back to you, if I may, Mrs Marr, you spoke
  20     about the fact that Project 2000 and the recognition of
  21     part 15 of children's nurses as a separate branch
  22     without progressing through adult nurses was an
  23     important recognition of the status of children's
  24     nursing, but you also gave evidence earlier of
  25     a particular perception that that form of qualification

   1     was not recognised outside the UK; it was not recognised
   2     in Europe.
   3        Is that first of all a matter of fact that it is
   4     not so recognised?
   5   MRS MARR: I want to say yes, but realise I am under oath,
   6     so I would need to go back to the actual documentation
   7     that spells it out.
   8   Q. So there is a problem about whether or not it may or may
   9     not be recognised that you may need to clarify?
  10   A. Yes. There is no qualification in the EU of children's
  11     nursing, but how they would practice in Europe, there
  12     might be a way round it that I am not 100 per cent sure
  13     of at the moment.
  14   Q. At the level, then, not of fact but of rumour or
  15     perception, has this been a problem since the inception
  16     of the Project 2000 training courses, or has it been
  17     a more recent concern on the part of potential would-be
  18     entrants?
  19   A. I think it has been a concern since students have become
  20     more aware of the European Union and the way things are
  21     progressing with the facility to work within Europe,
  22     sort of with the breakdown of the barriers, really.
  23   Q. Can you help us on the date of that developing
  24     perception? Is that early 90s, mid-90s, very recently?
  25   A. From my own perception, since taking up the role as

   1     director two years ago, it has become far more on
   2     people's agendas. I know Sue Burr from the RCN, who is
   3     giving evidence later, has all of these specific details
   4     on this issue.
   5   Q. I merely wanted to ask you, does that serve to undercut
   6     in any way the emphasis that was given by the changes in
   7     the registration requirements and the training courses
   8     upon the centrality of status of children's nursing?
   9   A. Yes, it does, and I do know that although we have in
  10     Project 2000 the four specialist branches -- adult,
  11     mental health, learning disability and children --
  12     within Europe the adult branch is still viewed as the
  13     generic nurse, the generalist, which puts the other
  14     smaller branches at a disadvantage.
  15        It is the one concept that they understand,
  16     because they do not have the smaller branches within
  17     Europe or the rest of the world. It is very much
  18     a generalist preparation for nursing, and then the
  19     specialism of children's nursing would be
  20     a post-qualifying experience.
  21   Q. We have been straying broadly over the areas of
  22     difficulties in recruitment to the field of children's
  23     nursing, and it is obviously a problem that has many
  24     strands to it. Can you put this particular strand in
  25     context. How important is it, or is it important at

   1     all, in shaping the entry of recruits to this particular
   2     branch of the profession?
   3   A. I think it is very important, because I think more than
   4     ever, students entering into the profession of nursing
   5     are far more aware of where they want to be in the
   6     future and career prospects, if not at the very outset
   7     of entering the course, as soon as they realise that
   8     their prospects are not as wide and varied as the adult
   9     students, that causes problems, because the perception
  10     is that the adult element is more important and carries
  11     more credence.
  12   MRS LE VAR: The Board has been in communication about this
  13     matter with the United Kingdom Central Council, and as
  14     you are aware, under their education commission, they
  15     are no doubt considering this issue and will probably
  16     have recommendations which will be initially for the
  17     short term, but then also addressing longer term
  18     issues. So we would expect this issue to be picked up
  19     by them.
  20   Q. If I could take you back towards the documents back in
  21     the early 1990s which set out the positions on the
  22     availability of trained paediatric nurses in ICUs in
  23     particular, and ask you to comment on those, if I could
  24     take you first to the Department of Health document,
  25     1991, The Welfare of Children and Young People in

   1     Hospital, Home file 2/1, that just gives us the title
   2     page to reference the document. At page 21 there are
   3     standards for an ICU set out there.
   4        I think it is right that those standards were then
   5     generally used for many purposes, including purchasing
   6     purposes, to specify the levels of standards of nursing
   7     care that should be provided within this particular
   8     setting.
   9        We see there that they speak in general terms of
  10     sufficiently specially trained medical nursing and
  11     midwifery staff being available, but if we scroll down
  12     the page to the "paediatric intensive care service", it
  13     references the document the Paediatric Association
  14     Working Party's definitions, and then sets out standards
  15     for paediatric intensive care and in particular, we see
  16     there the first element, that the nurse in charge should
  17     have an RSCN qualification or the child branch of
  18     Project 2000 should have been completed, and then we
  19     have an indirect reference to the ENB 415 qualification.
  20        Then more generally, the skills mix should be
  21     appropriate to the degree of dependency of the children
  22     cared for.
  23        Are you able to help us from the perspective of
  24     the ENB on the extent to which those standards were
  25     generally being met across the country at the time?

   1   A. In terms of our practice placements monitoring, the
   2     situation varies considerably across the country. Some
   3     units are meeting the standards, but others are not.
   4     Again, we could get you more precise information if you
   5     need it.
   6   Q. In turning back the clock to the date of that document,
   7     would your answer have been as true for that as well as
   8     for now?
   9   A. The situation has improved, but it is slower than
  10     anticipated.
  11   Q. If we turn to the audit commission report in 1993,
  12     "Children First", a study of hospital services, this is
  13     at Home file 1, page 132. Again, that will be the title
  14     page. Is this a document you are familiar with?
  15   A. Yes.
  16   Q. If we look at page 156, there is there first of all
  17     a short paragraph on the problems, some staff who care
  18     for children lack special skills of dealing with
  19     children, and also a problem of referrals there to
  20     appropriate tertiary centres.
  21        If we can just scroll through that page, please,
  22     you have a chance to read first of all paragraph 41.
  23     Then if we can turn to page 158, this deals specifically
  24     with nursing. The remainder of the document deals with
  25     medical staff and doctors.

   1        If you turn towards the bottom of that page,
   2     please, if you would just like to take a moment to read
   3     that, that is a statement really of the need for
   4     specialist paediatric care.
   5        Over the page, page 159, the same point is
   6     continued at the top of the page, setting out standards
   7     that should be attained, and then the findings of the
   8     Audit Commission's report on the availability of those
   9     nurses, starting with the bar charts as the
  10     page continues.
  11        Do not trouble with the detail of the finding, but
  12     the picture fairly clear from the charts.
  13        If we go to the bottom of the page which gives the
  14     whole, and at night-time in particular, where the
  15     problem is particularly acute.
  16        Then over the page, please, page 160, there is
  17     a particular conclusion set out there that:
  18        "A major national study of career prospects for
  19     RCNs has identified two main reasons for their scarcity:
  20     firstly that managers did not perceive a need for RCNs
  21     and secondly that there were lack of prospects for
  22     career development in sick children's nursing and the
  23     low status of the work was perceived to be a problem by
  24     nurses in general."
  25        Were those findings you recognised from your

   1     experience of the ENB?
   2   A. Yes, they were. They frequently come up in our practice
   3     placement reports.
   4   Q. If we turn then, please, to page 164, the
   5     recommendations of the Audit Commission on this point
   6     are set out. There they say that already particular
   7     steps that can be taken to make more effective use of
   8     the RSCNs that exist, but then it goes on, in
   9     paragraph 66, to say:
  10        "If more RSCNs are needed managers should: begin
  11     a policy of positive encouragement to attract newly
  12     qualified and existing RSCNs back to children's
  13     nursing ... secondly [the second paragraph], to increase
  14     the availability of post-registration training."
  15        It mentions there the fact that some Regional
  16     Health Authorities were top-slicing funding for that
  17     form of training. Then the mention that that was not
  18     necessarily the case; that over half of Health
  19     Authorities had no strategy for secondment.
  20   A. Yes.
  21   Q. Can you help us generally as to the availability of
  22     strategies or the extent of the development of
  23     strategies for secondment that would have enabled nurses
  24     with, say, adult experience, to qualify as RSCNs, or
  25     RSCNs to get further post-registration experience?

   1   A. From the point of view of the Board, we recently
   2     developed two circulars looking at the policy to enable
   3     a more flexible access to post-qualifying education.
   4        The first one was to enable those general or adult
   5     nurses working within the field of children's care to
   6     have their prior learning and experience recognised, and
   7     a reduction from 53 weeks down to a minimum of 26.
   8        This was similar to the policy document that you
   9     showed us earlier, whereby previously practitioners had
  10     to have a minimum of three years experience working with
  11     sick children.
  12        This we found excluded quite a number of
  13     practitioners from accessing in the programme so it was
  14     a case of looking at the outcomes of the 53-week
  15     programme and practitioners coming forward with
  16     a portfolio of evidence that would be scrutinised and
  17     then a programme developed to suit their specific needs.
  18   Q. So that is a specific response on the part of the ENB to
  19     widen opportunities to get on to appropriate training
  20     courses to make sure that practical experience is
  21     properly recognised, but turning the clock back on the
  22     date of this document or thereabouts, going back to
  23     1991/92/93, what were the obstacles that might be placed
  24     in front of a nurse who was working with children as
  25     well as adults, and began to perceive a need for further

   1     training?
   2   A. The perceived need for further training was, both by
   3     some of the practitioners and their managers, a short,
   4     sharp module on intensive care for children. The Board
   5     did develop a programme that was called the "N82" for
   6     this specific reason, but there was quite a lot of
   7     discussion within the field of children's nursing
   8     because of the mixed messages that developing such
   9     a programme gave out to the profession, that sort of
  10     anyone could have a short, sharp burst of education and
  11     be deemed able to care for children. It really did not
  12     address the fundamental differences that make children
  13     unique in children who are receiving health care.
  14   Q. Did it prove to be a course that was widely offered,
  15     then?
  16   A. No, I think at the end of the day there was one
  17     institution that developed it, had it approved and ran
  18     it, and actually one of the outcomes of the programme
  19     was to focus in on the practitioner and what they did
  20     not know, so that they could then develop their further
  21     education to address those deficits.
  22   Q. Let us then focus not on that course but on
  23     a practitioner who wanted and identified a need to go
  24     either on the ENB 415, or alternatively, to qualify as
  25     an RSCN, having already obtained some practical

   1     experience as an RGN.
   2        What would such a person have to do in order to
   3     get support from an employer, from Health Authorities,
   4     in order to be obtaining that form of further training?
   5   A. They would need to secure a place on an approved
   6     programme, and the funding for which could either have
   7     come from the regional office or employer funds, and
   8     around this time, additional funding was made available
   9     through the regional office to enable practitioners to
  10     take advantage of the educational opportunities that
  11     were on offer.
  12   Q. Was that to encourage further education generally, or
  13     particular types of post-qualification registration and
  14     training?
  15   A. It was paediatrics. I am trying to think in the field
  16     of paediatrics, was it anything specific. I would need
  17     to come back to you. I am not aware if there were any
  18     other specific areas that were being addressed.
  19   Q. But you think in 1992/93, because of the emphasis on
  20     paediatric skill shortage and paediatric intensive care
  21     skill shortage, that money was being made available by
  22     the Regional Health Authorities to enable secondment of
  23     staff to training in those particular areas?
  24   A. Yes.
  25   Q. From the point of view of the hospital concerned, was

   1     this something that was welcomed?
   2   A. It was welcomed, but in some instances, where you had
   3     got an adult intensive care unit that occasionally cared
   4     for children, managers were reluctant to second students
   5     to undertake the children's qualification because, upon
   6     completion, very often the practitioners did not return
   7     to that area; they really wanted to concentrate on
   8     caring for children in the dedicated children's units.
   9     So as fast as they were seconding these members of
  10     staff, they were losing them at the same time.
  11   Q. If money was made available from the Regional Health
  12     Authority for this form of training, did this cover the
  13     cost of seconding staff to replace the trainee whilst he
  14     or she was away?
  15   A. For the post-registration programmes, yes, it did. I am
  16     not sure about the pre-registration programme. No. We
  17     would need to find that, during that time, whether
  18     placement funds were made available.
  19   Q. So provided a nurse could secure access to those
  20     particular forms of funding, the hospital would have no
  21     direct financial loss in using a member of staff to that
  22     form of training for the period of time during which the
  23     course took place?
  24   A. That is true, yes.
  25   MRS LE VAR: I am sorry, if I can clarify, you asked the

   1     funding in relation to pre-registration? If the places
   2     were there, the funding would have been in terms of
   3     bursaries. It was the special funding in relation to
   4     post-registration programmes and paediatric intensive
   5     care that was a special arrangement, rather than the
   6     straightforward funding arrangement for pre-registration
   7     programmes.
   8   Q. But from the point of view of the institution concerned,
   9     if you had secured that post-registration funding, they
  10     would not lose out financially.
  11        What about any institution that itself identified
  12     a need for this form of training, but was not able to
  13     secure Regional Health Authority funding for it?
  14   A. Then there could be employer funds made available, and
  15     in some instances, practitioners have funded themselves.
  16   Q. Are you able to help us on the general availability of
  17     employer funding for this form of qualifications,
  18     post-registration qualifications in the 1990s?
  19   A. I think in very general terms, post-registration
  20     opportunities are available in theory to all nurses. In
  21     practice, the percentage -- and I do not have a definite
  22     percentage to give; I know that in the past I have
  23     undertaken such surveys, and it was a minority of
  24     100 per cent population that in fact did have, in
  25     particular, a long course of 24 weeks rather than one

   1     of, say, 10 days. So the overall general availability
   2     was limited.
   3   Q. What was the attitude of employers in sending their
   4     staff off on those courses, if they had to fund them
   5     themselves?
   6   A. There were always a range of considerations. The need
   7     might have been identified in relation to a deficiency
   8     in the area; it might have been through appraisal,
   9     through interest shown by the particular nurse, but the
  10     manager would then have to look at the availability of
  11     funding in relation to those funds that were needed to
  12     continue the service so the education funding and
  13     training funding always have to be balanced against the
  14     total funding available.
  15   Q. We have looked generally at documents in 1991/93, before
  16     that in 1987, that looked at the difficulties in
  17     availability of paediatric nursing and paediatric
  18     intensive care nursing in particular.
  19        Do you have any comments to add on the general
  20     picture of their availability now, to bring the position
  21     up to date?
  22   MRS MARR: Availability of courses?
  23   Q. Generally, first, the question of the skills shortage,
  24     if it still exists, for both paediatric nursing and
  25     paediatric intensive care nursing?

   1   A. There is still a deficit of appropriately qualified
   2     children's nurses within intensive care units across the
   3     country. The ENB again developed policy to enable
   4     practitioners to acquire a children's nursing
   5     qualification combined with the intensive care 415 in
   6     one of the programmes, and this policy came out last
   7     year, but there has been very slow response; we have
   8     universities who have expressed an interest, so upon
   9     further exploration, we became aware of the difficulties
  10     out there within the service in their response to the
  11     report "A Bridge to the Future."
  12        There is still some positioning going on and
  13     determining who the lead centres will be, and also, an
  14     added complication in terms of setting standards for
  15     retrieval and transportation of critically ill children,
  16     when, within burns and plastics and neurosurgery, they
  17     have already set their standards and are sort of saying,
  18     "Why do we need to change?"
  19        So we can now understand why there has been a slow
  20     response to this very flexible approach to acquiring
  21     both the children's qualification and the ENB 415.
  22   Q. You are speaking there from the ENB's perspective of the
  23     development of the EPLO 1, EPLO 5 course frameworks?
  24   A. That is right, yes.
  25   Q. But you found, I think, that the take-up of those

   1     courses, in so far as the interest from universities in
   2     offering them, has been limited?
   3   A. Yes. We have not had any university yet come forward
   4     with a definitive programme that they wish to have
   5     approved, until they can work in partnership with the
   6     service to determine precisely the training needs of
   7     these professionals working with critically ill
   8     children.
   9   Q. And the training needs will not be sorted until what we
  10     might call the "politicking" that is arising out of the
  11     framework, the bridge for the future, has been sorted?
  12   A. That is right, yes.
  13   Q. I think you are saying that is still an ongoing issue?
  14   A. Yes.
  15   MISS GREY: Thank you very much. Mrs Le Var?
  16   MRS LE VAR: May I add one point. You asked about the
  17     pre-registration availability, and certainly, the
  18     numbers of commissions increased considerably over the
  19     last five years or so, even at the time when the
  20     commission's numbers for adult nurses went down. This
  21     is going back certainly some five years, but the numbers
  22     of children's nurses never took that dip; they continued
  23     to rise and we have watched that progress with
  24     satisfaction.
  25   MISS GREY: I have asked questions over a long period of

   1     time. Is there anything that either of you would like
   2     to add to the evidence you have given, or if you do not
   3     wish to come back on that invitation immediately, let me
   4     just add that if you wish at any time to write in
   5     further to the Inquiry, whether to clarify anything that
   6     has been said this morning or to make any new points,
   7     you will be more than welcome to do so. For the moment,
   8     is there anything that either of you would like to add?
   9   MRS MARR: I think just one point in terms of new
  10     developments which are coming to light, to ensure that
  11     children are being cared for at least under the guidance
  12     of a qualified children's nurse within units and Trusts,
  13     we are beginning to see much more rotation of children's
  14     qualified nurses through different areas where children
  15     are being cared for, like A & E and high dependency, and
  16     adult wards where children are being cared for. So we
  17     are seeing the emergence of sort of the consultant
  18     nurse, the specialist nurse, who provides this support
  19     for perhaps a whole Trust.
  20   Q. Could I just pick up on that a little further by asking
  21     you this: we have spoken throughout this morning and
  22     this afternoon of the need for properly trained nurses
  23     and qualified nurses. That, in a sense, has assumed
  24     something that perhaps I would just like to invite you
  25     to comment on, which is that the qualification attained

   1     by the nurse does make a difference to the outcome; that
   2     children's care, children's recovery from illness is
   3     directly affected by the extent to which nurses are
   4     qualified to nurse.
   5        Can I just ask you to comment generally on perhaps
   6     a rather large area, which is, what is the evidence for
   7     that particular assumption, that attaining levels of
   8     qualifications of children's nurses actually makes
   9     a difference to the outcome in terms of care?
  10   A. I am not aware of any evidence. Again, we may need to
  11     come back to that. There are lots of anecdotal
  12     examples.
  13   Q. I put that to you at a late stage in the proceedings
  14     today. If you would like to come back on that later?
  15   MRS LE VAR: We would like to come back on that later.
  16     Certainly the clear issue is that those that have not
  17     been really trained and prepared to nurse children
  18     simply do not acquire everything that is required
  19     through practice, even, and then it is questionable that
  20     without the proper preparation that it actually takes to
  21     become a competent children's nurse, it takes more than
  22     just going to the working area and trying to pick on the
  23     intricacies of administration of medicines, for
  24     example. So there is a very clear link of being
  25     a competent nurse in that area, and then the results of

   1     that care. But in terms of producing general research
   2     evidence, we would need to look at that.
   3   MISS GREY: Thank you very much. The Panel may have some
   4     questions for you.
   5             Examined by THE PANEL:
   6   MRS MACLEAN: Yes. You have been very helpful in talking to
   7     us about the shortages of specialist children's nurses
   8     and your problems in developing training courses. Could
   9     you tell us anything about regional variation in those
  10     shortages and, in particular, whether you have any
  11     information about the position in the South West?
  12   MRS MARR: We do not have statistics with us today to answer
  13     that question. Again, we could produce it.
  14   Q. That is very helpful, thank you. One other point which
  15     may or may not be within your brief: we have been
  16     learning a little about the work of Cardiac Liaison
  17     Nurses. I wonder if you can help me with any
  18     information about what kind of qualifications you might
  19     expect them to hold, the qualifications which would be
  20     appropriate for them? Are there any specialist courses
  21     available?
  22   MRS MARR: If it was Cardiac Liaison Nurses in respect
  23     of caring for children, yes. I would expect them to
  24     have the children's qualification, either the RSCN or
  25     part 15, and then a post-qualification specialist

   1     clinical course in cardiac care for children, and not
   2     necessarily qualifications, but I would expect this
   3     person to have a network of contacts, both nationally
   4     and internationally, and actually to be at the forefront
   5     of cardiac care for children.
   6        I am not aware yet if there is a specialist
   7     practitioner programme available in this field of care,
   8     but if there is not, this is an emerging trend, so
   9     I would certainly expect to see that development and for
  10     these Cardiac Liaison Nurses to be at least at the level
  11     of specialist practitioner, and with the new government
  12     proposals for the specialist, the consultant, that this
  13     would be an avenue that we would expect the highest
  14     level of qualification, expertise and knowledge to carry
  15     out this role.
  16   MRS MACLEAN: Thank you.
  17   MRS HOWARD: I have just a couple of questions. You spent
  18     some time explaining the issue of supervision of
  19     students in areas which have been accredited for
  20     children's courses. If I could refer you to witness
  21     63/20, if that is possible on the screen, it is in
  22     respect of paragraph 4.3.2. I am particularly
  23     interested in respect of general nurse students and
  24     whether you have any comment to make in the final
  25     statement that:

   1        "Institutions not offering a statutory children's
   2     nursing course did not perceive the circular as having
   3     any relevance to them."
   4        Do you have any comment to make about general
   5     nurse students who would be caring for children in
   6     a non-accredited training area and any comments in
   7     respect of that paragraph.
   8   MRS LE VAR: I do not think that we have figures in our
   9     heads to produce on that, but clearly the initiatives
  10     that the Board has brought into existence have been
  11     implemented primarily in relation to children's wards
  12     rather than the adult wards, and that they tend to be
  13     the last ones to want to first of all see the need for
  14     them actually to have a paediatric nurse there. They
  15     are quite complex problems, because often they are to do
  16     with geographical problems in the actual hospital or
  17     trust, so that it is not just simply a staffing problem,
  18     but staffing is one part of it. If, for example, the
  19     adult nurse gains the paediatric qualification, as has
  20     been indicated earlier, then that particular nurse may
  21     not wish to stay in the adult environment. So there are
  22     complexities both ways.
  23   Q. Can I just take that a little step further? If you had
  24     an area which was not designated as a children's
  25     training area but did provide some care for children,

   1     would the Board have a view in terms of the training of
   2     the general nurse student, their access to children and
   3     their supervision of those children?
   4   A. Yes. In that situation we would insist on a children's
   5     qualifying nurse as supervisor and assessor of that
   6     general nurse undertaking a children's focused
   7     experience.
   8   Q. That would stand for the period from 1984 through to
   9     now?
  10   A. I cannot go back as far as 1984. I am just going since
  11     Project 2000, but again, we could find that.
  12        Just one other point, where we have children's
  13     nursing students accessing placements that are
  14     non-dedicated children's areas and there is not
  15     a suitably qualified children's nurse, then the tutor
  16     with the children's nursing qualification is the one who
  17     provides the report and supervises and assesses.
  18   MRS LE VAR: I would like to add to that. As a general
  19     principle, that situation would have applied in the
  20     1980s as well. Greater difficulties then than now, but
  21     as a general principle, it would have applied. That
  22     would have been the Board's desire, to have better
  23     qualified paediatric nurses.
  24   Q. You mentioned children's tutors, children's nurse
  25     tutors. Given that we have heard this morning a good

   1     deal about shortage of children's nurses, does the Board
   2     have any comment about the availability of children's
   3     nurse tutors in the practice placement area, and also
   4     the availability of nurse lecturers in the University
   5     situation to provide the courses that we have heard
   6     about?
   7   A. There have been difficulties in terms of the shortage of
   8     children's qualified nurse teachers with a paediatric
   9     intensive care qualification as well. What we have
  10     done, as the statutory body, is to encourage
  11     a tripartite relationship between the nurse tutor with
  12     a children's qualification, linking up to paediatric
  13     intensive care areas, with a children's qualified nurse
  14     with the 415. So, between them, they have the knowledge
  15     and expertise to deliver the programme. Several
  16     lecturer practitioner posts have been established, and
  17     it seems to have got over that initial barrier to
  18     further developments.
  19   MRS HOWARD: Thank you very much.
  20   PROFESSOR JARMAN: On the same page that we have up in front
  21     of us, which Mrs Howard was referring to, my general
  22     impression is that the ENB is in favour of units where
  23     children are nursed, the nurses having
  24     children-training. It says at the very bottom of that
  25     page, in paragraph 5.1.2, that 85.6 per cent of units

   1     where children are nursed, care is provided by nurses
   2     who do not told RSCN qualification.
   3        That qualification has been going since 1923,
   4     I gather.
   5        As Miss Grey showed us earlier, the Audit
   6     Commission survey shows that it is somewhat similar
   7     now.
   8        My question really is, first of all, who actually
   9     is responsible for getting what you consider to be
  10     a better situation? Whose ultimate responsibility is
  11     it? Is it the ENB or the Department of Health, the RCN,
  12     or is it nobody? I just want you to give me your
  13     general impressions.
  14   MRS LE VAR: It is a Health Service responsibility, so the
  15     Board does not have the power to have that
  16     responsibility; the Board can influence and the Board
  17     can certainly have responsibility in relation to the
  18     areas which are approved for training, but that is where
  19     it stops. The general availability of children's nurses
  20     is determined by the NHS Executive and the consortia
  21     which commission education and which lead to the
  22     provision of additional children's nurses.
  23   Q. So although it is your opinion that it should be a high
  24     proportion, it is not actually your responsibility; it
  25     is the Health Service, I think you said. You mean who,

   1     the NHS Executive or the Department of Health?
   2   A. The broad Department of Health, and then specifically
   3     within the Department of Health and the NHS Executive,
   4     and under the NHS Executive, the education and training
   5     commissioning consortia related to their workforce
   6     planning.
   7   Q. My question really is: this has been going on so long,
   8     why did nothing happen about this? You would pass it
   9     back to the same people, would you, or not?
  10   A. I think as we just recently said, certainly in the last
  11     five or six years, there has been significant
  12     improvement in the pre-registration figures, and that
  13     has been a significant and a very welcome trend so that
  14     the real need for additional nurses has been picked up,
  15     I feel, very clearly.
  16   MRS MARR: I was going to say that in reality, the situation
  17     is quite difficult, because where you have adult areas
  18     that occasionally care for children, it is not
  19     cost-effective for the managers to employ enough
  20     children's qualified nurses to cover the eventuality of
  21     having children admitted.
  22        Another development is where children's qualified
  23     nurses from the children's areas then go to work on that
  24     ward when a child is admitted; but then, that flies in
  25     the face of the general philosophy of children's care,

   1     that they should have the right environment and access
   2     to nursery nurses, the toys and the general atmosphere.
   3   Q. When you say it is not cost-effective, we do not really
   4     know how effective children's nurses are or not,
   5     although there is some evidence that intensive care is
   6     helpful in reducing mortalities. Are you using the term
   7     in that sort of context, or not? What do you mean by
   8     "cost-effective"?
   9   A. Cost-effective in as much as they would have their whole
  10     time equivalent staffing levels for a particular ward
  11     dependent upon the patient throughput, and if they were
  12     to employ a qualified children's nurse, what would that
  13     nurse be doing for some of the time when there were no
  14     children?
  15   Q. I see, yes. Earlier on in this same document, page 6,
  16     I want to clarify the first question that Miss Grey
  17     asked you this morning, as it was something which I just
  18     do not understand at all.
  19        Mr Smith said that 98 per cent of the ENB grant
  20     came from the government, and then, at the end of the
  21     financial year, 1992/93, at the end of March 1993, the
  22     proportion of the government grant relating to the
  23     funding of salaries and incidental expenses of the
  24     Colleges of Nursing and Midwifery in England --
  25   THE CHAIRMAN: This is page 5.

   1   PROFESSOR JARMAN: -- page 5, I am sorry, was devolved to
   2     the Regional Health Authorities. Do you see that bit?
   3     This reduced your grant by œ130m. So presumably that
   4     œ130m was the cost of the salaries and incidental
   5     expenses of the Colleges of Nursing and Midwifery.
   6   MRS LE VAR: Yes. The first figure, the œ130m, relates to
   7     basic nursing education funding. The Board simply
   8     distributed this through education and advisory groups,
   9     which existed in the 14 regions. It was then decided
  10     that this actual commissioning of the training
  11     placements and the whole funding would be undertaken by
  12     the Regional Health Authorities (which in due course
  13     devolved them to the education consortia). It was in
  14     April 1993 that the Board lost the œ130m which went to
  15     the regions from the Board. The following year, there
  16     was an additional sum of money, œ10m, which also went to
  17     the regions. This related to teacher training, which we
  18     had also directly funded prior to 1994.
  19   Q. So that reduced your funding, you say; you were left
  20     with 83 per cent. It says the government grant was
  21     reduced to 83 per cent of the Board's total revenue,
  22     having taken away the œ130m. Can you see the line?
  23     It says:
  24        "This in effect reduced the proportion of
  25     government grant to 83 per cent relative to the Board's

   1     total revenue."
   2   A. Yes. The remaining amount of the Board's budget, which
   3     consists of government grant, indexes for students and
   4     a few other avenues of funding, such as conferences,
   5     publications, out of that total budget, the government
   6     grant would have made up 83 per cent, whereas previously
   7     it would have been a far higher percentage.
   8   Q. You said on page 53, line 6, in today's hearing, that
   9     this left the ENB with its main function of approval of
  10     institutions and programmes?
  11   THE CHAIRMAN: Page 6, the page after the page we were just
  12     looking at?
  13   PROFESSOR JARMAN: No, I am going off today's hearing,
  14     page 53 line 6.
  15   THE CHAIRMAN: I am sorry.
  16   PROFESSOR JARMAN: It was said that it left the ENB with the
  17     main function of instituting approval and programmes.
  18     Miss Grey clarified that by saying, "purely
  19     a professional quality assurance organisation".
  20   A. That is correct. This additional function of
  21     distributing the funding ceased, and the Board is the
  22     statutory body with the primary responsibility of
  23     approving institutions and programmes.
  24   Q. So that was the 83 per cent of the funding that was
  25     left?

   1   A. Yes.
   2   Q. So if you scale up the 15 per cent, that means that is
   3     œ720m for that quality assurance?
   4   A. No. I do not think that sentence is clearly stated,
   5     because the effect of having lost œ130m meant -- the
   6     total budget from which the œ130m went would have been
   7     about œ157m at that time, so the total budget reduced to
   8     about œ27m, and then another œ10m went the following
   9     year, so that came to around œ17m. That has gradually
  10     gone down every single year, through efficiency savings,
  11     et cetera. We are now down to the sum which is,
  12     I believe, on the following page , which is now about
  13     œ7m.
  14        So the approval function is not that expensive.
  15   PROFESSOR JARMAN: I still do not completely understand it,
  16     but I would like to see the details of the funding, if
  17     I could, at a later date.
  18   THE CHAIRMAN: I have no questions. May I, on behalf of the
  19     Panel, thank you very much for coming and helping us
  20     today with your evidence. I would like to pay tribute
  21     to Miss Grey and to a degree to the way that we have
  22     created this process of holding hearings, that we can
  23     hear you together sitting side by side and are able to
  24     take advantage of the fact that you can talk to each
  25     other and confer before helping us with your evidence.

   1     That, I think, has been helpful. If you like, it is an
   2     indication of the flexibility which we are trying to
   3     inject into this hearing, because, after all, we are
   4     trying to learn from whatever source we can learn.
   5        So I am very grateful. Miss Grey, is there
   6     anything else you would wish to add?
   7   MISS GREY: No, merely to thank both of you for coming to
   8     today and giving your evidence. Thank you very much.
   9            (The witnesses withdrew)
  10   MR LANGSTAFF: Sir, I know that you have it well in mind
  11     that today is the last day that we will hear any
  12     evidence before the Easter break, and I know that
  13     discussions have been taking place in relation to when
  14     next we shall meet again.
  15   THE CHAIRMAN: Thank you, Mr Langstaff. Just let me make
  16     a few comments before we close today, first of all, to
  17     make an announcement concerning the Inquiry's
  18     documentation and the timetable for hearings after the
  19     Easter break.
  20        I am pleased the say that since we started our
  21     oral hearings on March 16th, we have made good
  22     progress. We have completed the first of our six blocks
  23     of evidence and we have made a good start on Block 2, so
  24     the Inquiry is ahead of schedule.
  25        If I may, I would like to express the thanks of

   1     all of us on the Panel to everyone.
   2        At the same time, below decks, if I may use that
   3     term to describe the two floors below us, the massive
   4     task of assembling the core documentation has been
   5     continuing. I am delighted to be able to announce that
   6     the first two CD ROMs of documents are in production and
   7     will be distributed to legal representatives before
   8     Easter. These CDs will contain relevant material
   9     submitted to the Inquiry from the United Bristol
  10     Healthcare Trust, the Welsh Office and the Department of
  11     Health.
  12        To give you an idea of the size of the task which
  13     has been undertaken by the Inquiry team, the Trust alone
  14     submitted approximately 90,000 pages of material, all of
  15     which has now been read and assimilated.
  16        The core documents on the CD which we are issuing
  17     this week run to some 15,000 pages.
  18        The CDs will be issued in searchable form.
  19     However, even with electronic assistance, the
  20     assimilation of the documentation is a considerable
  21     task. The Inquiry recognises the that potential
  22     witnesses in particular will be better able to assist
  23     the Inquiry if they have had the opportunity to digest
  24     the relevant documentary material by the time they give
  25     their evidence.

   1        We are also conscious of the fact that the Easter
   2     holiday period gives a very limited time for this if the
   3     hearings were to resume on 12th April as we originally
   4     planned, and could cause some inconvenience to some
   5     witnesses, which we would be most anxious to avoid.
   6        Thus, we shall reconvene on 19th April at
   7     10.30 am.
   8        In that week, we hope to complete evidence from
   9     the Royal Colleges, before turning to witnesses from the
  10     Welsh Office and the Department of Health.
  11        The last thing I would mention is that I received
  12     a letter from Mr Lissack QC and his colleagues
  13     concerning the role of counsel other than Counsel to the
  14     Inquiry. I may say, I am grateful to them for the tone
  15     and for the content of their letter.
  16        Many of the matters which they raise can be the
  17     subject of further discussions with the solicitors to
  18     the Inquiry, but may I add this: the Inquiry sees the
  19     oral hearings as a supplement to the written evidence
  20     process. Furthermore, as I have made plain in the past,
  21     the Inquiry expects that, save in exceptional
  22     circumstances, questions will be put by one of the three
  23     Counsel to the Inquiry.
  24        We recognise that there may be exceptional
  25     circumstances when this is not so.

   1        A protocol, however, may introduce unnecessary
   2     rigidity into the matter, which will inevitably have to
   3     be addressed on a case-by-case basis and may defeat the
   4     twin objects of ensuring that the Inquiry is both fair
   5     and efficient.
   6        Since I recognise the desirability of identifying
   7     issues before they arise so that they may be dealt with,
   8     I continue to be happy to consider any further matters,
   9     but I would remind all legal representatives, again,
  10     that we are not a court and that we are not adopting the
  11     procedures of a court; we are conducting a Public
  12     Inquiry. In doing our duty under our terms of
  13     reference, we are not helped by having sides or cases
  14     advanced before us. There are no sides, nor are there
  15     cases to be put.
  16        We will, therefore, adjourn now and reconvene on
  17     Monday, 19th April at 10.30 in the morning.
  18   MR LANGSTAFF: One last matter, before you adjourn,
  19     Chairman, and essentially, because I am aware, as we all
  20     are, that the proceedings of the Inquiry have attracted
  21     considerable interest on the Internet, inevitably those
  22     who follow proceedings in this way may not turn on
  23     tomorrow and if they fail to do so, they might miss an
  24     important announcement as to the detailed composition of
  25     the expert group, which we know is now very close to

   1     reaching fruition and has a very sizeable number of
   2     experts covering the principal disciplines which might
   3     be potentially involved in the issues in this Inquiry.
   4        If I can just simply flag up the announcement in
   5     detail which is to be made tomorrow, delayed until then
   6     as I understand for very good administrative reasons,
   7     and reasons essentially of comity with those who are the
   8     experts, the immediate employers or managers.
   9   THE CHAIRMAN: I am very grateful to you, Mr Langstaff.
  10     That is the case and that will take place tomorrow.
  11     Thank you. We now adjourn.
  12   (2.20 pm)
  13     (Adjourned until 10.30 am on Monday, 19th April 1999)

		13.03.99 INFORMATION NOTE:

It is now anticipated that oral hearings will resume in Bristol during the week beginning April 23. (see Forthcoming Events)

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     2                                I N D E X
     3
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     6             1 ... PROFESSOR GEORGE ALBERTI (Sworn)
     7             2 ... Examined by MR LANGSTAFF
     8            46 ... Examined by THE PANEL
     9
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    11            49 ... MRS SUSAN JANE MARR (Sworn)
    12            49 ... MRS RITA LE VAR (Sworn)
    13            49 ... Examined by MISS GREY
    14           127 ... Examined by THE PANEL
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Published by the Bristol Royal Infirmary Inquiry, July 2001
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