Annex A > Chapter 11 - Referrals > Referrals to Bristol - information available to referring clinicians about standards at Bristol or elsewhere and factors influencing referral patterns
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Referrals to Bristol - information available to referring clinicians about standards at Bristol or elsewhere and factors influencing referral patterns
27 Mr Steven Owen [34] told the Inquiry:
`I was constantly being told that clinicians had their favourite units, they established working relationships with the people, and in practice, if they referred to unit A, whatever other units were or were not doing, they would in all probability continue to refer to unit A.' [35]
28 Professor David Baum, then President of the Royal College of Paediatrics and Child Health (RCPCH), also explained the culture in relation to referrals at the time of the Inquiry's Terms of Reference:
`My memory of the context of the time is that this was not a culture - which I think is a desirable culture, but it was not the culture - of, "This has been the quality of my clinical performance with these outcome measures for the last five years, those are my cards, do you like them or do you want somebody else's cards?" It was very much more broadly an atmospheric of, "This is a good guy, this is not such a good guy". But within that has to be titrated the urgency of the matter, so if the matter was urgent or were urgent tomorrow, there would be the other consideration of, "Is it on my patch or am I going to look at the cards to such a degree I am going to send the patient to another patch?" ... in 1990/1994, as a paediatrician, if I feel this child is unwell and there is a cardiological problem of some severity, it would not, I believe, have entered my consciousness to think, "What is the quality, outcome, performance, audit, of my colleague cardiologists?" I would say, "There are competent consultant-trained cardiologists on this corridor who are my colleagues who I trust through their training and I trust them as individuals, that I will refer the care of the baby".' [36]
29 Asked whether his answer would have been any different if he had been a paediatrician in a district general hospital who was referring children to a paediatric cardiologist in another hospital, Professor Baum said:
`... it would have been different, but the difference would have still hung on an atmospheric of quality of service, rather than on any published measured audit of accuracy of diagnostic skills.'
He said that the information on which he would have based judgments was:
`Many strands. They would include a reputation of diagnostic skills. And how does that reputation get about? Well, there are the value of clinical meetings, the value of first- and second-hand discussions, the gossip network. So there would be diagnostic skills; there would be matters of professional courtesy; again, the gossip vine of how they are with parents who are worried about their sick child; how they are in terms of their relationship with their firm, with their juniors, as trainers, with their colleagues. There would be an element of their efficiency professionally, of how quickly they could accommodate what I am saying, "This is an emergency", and how far they will put themselves out to come to see the child in my clinic in the DGH or to arrange transport and so forth, and many other elements. So it is professional diagnostic skills and other elements of professionalism.' [37]
30 Dr William Reith, Honorary Secretary of the Royal College of General Practitioners (RCGP), told the Inquiry that referrals by GPs directly to paediatric cardiologists would be rare. A GP would rarely encounter a child with a congenital heart defect in his or her practice due to the rarity of the condition. The average list size would only contain ten patients of all ages affected by congenital heart disease, with one new case arising about every five years. Dr Reith said that as the initial diagnosis of a heart defect would be likely to be made by a paediatrician or a paediatric cardiologist, by the time a GP had contact with the child, it might well be that both diagnosis and a course of treatment, even surgery, had taken place. [38]
31 Asked, in the event that a GP was considering whether to refer to a paediatrician, on what data or information the GP's judgment as to the adequacy of the service likely to be provided by that paediatrician would have been based, Dr Reith told the Inquiry:
`Not very much, in all honesty. I mean, much of the general practitioner's decision to refer will be on the basis of personal knowledge. Over time, a general practitioner will get to form a view, an opinion, on the range of abilities and indeed the range of specialisation of consultant colleagues, and again, different specialties have evolved at different rates, so, for example, in surgery, there was some specialisation some time ago, a number of years ago, in many centres into surgeons specialising in breast surgery, thyroid surgery and that sort of thing. In the surgical condition of ophthalmology, it is only now there is specialisation into those dealing with retinal problems, and so on, so again it must be taken in that context.
`Whether or not one would refer in the particular instance to a paediatrician or a paediatric cardiologist would depend to an extent on local practice. Probably, a large chunk of the population and their GPs do not have immediate access to a major hospital and many of them will be seen through district general hospitals which will tend to have a general paediatrician rather than a paediatric cardiologist. That again, I am sure you will appreciate, is due to population size and so on. So there are many parts of the country where a general practitioner will refer on to a general paediatrician. There may be five or six paediatricians in the hospital and perhaps one or two of them might have a special interest in paediatric cardiology. That would not be the whole nature of their work, but obviously they have a particular interest in that. [39]
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Footnotes
[34] Administrative Secretary of the SRSAG from January 1992-February 1996
[36] T18 p.71-2 Professor Baum
[37] T18 p.70-4 Professor Baum
[38] WIT 0059 0010 Dr Reith