24th June 1999
Today the Inquiry heard from Liz Jenkins and Sue Burr of the Royal College of Nursing (RCN). They came to give evidence about the role of the RCN comparing it with the role of the UK Central Council for Nursing, Midwifery and Health Visiting (UKCC), British Medical Association (BMA) and the Medical Royal Colleges. They discussed the RCNs aim of setting and raising standards of best practice to promote the art and science of nursing. Mrs Burr described her role as Paediatric Nurse Advisor to the RCN as being to represent childrens voices in national health debate. They went on to talk about the shortage of trained paediatric nurses (RSCNs) and difficulties around recruitment, especially to units looking after adults as well as children. They then focussed on national guidelines, dissemination, implementation and the attitudes of Trusts towards the guidelines. The responsibility of the Director of Nursing or Nurse Advisor in terms of the conflict between quality and patient care issues set against resource allocation was debated. Mrs Jenkins and Mrs Burr then answered questions about nurse training, education and nursing audit. They went on to describe the value of counselling for staff and the opportunities for nurses to raise issues of concern with managers and the RCN.
The hearings were adjourned for the week and will be resumed on Monday 5 July at 10.30 a.m.
1 Day 34, 24th June 1999 2 (9.30 am) 3 THE CHAIRMAN: Good morning, everyone. Good morning, 4 Miss Grey. 5 MISS GREY: This morning we have the benefit of hearing from 6 two witnesses, Miss Sue Burr, who is the Paediatric 7 Nurse Adviser of the Royal College of Nursing, and from 8 Mrs Liz Jenkins, who is the Assistant General Secretary 9 of the Royal College of Nursing. 10 We had proposed, subject to your agreement, that 11 we would ask them to give evidence together with the two 12 of them covering the topics that they are most 13 comfortable with at the same time, hopefully that course 14 of action should not pose too many problems for the 15 stenographer or for anyone else. 16 THE CHAIRMAN: We have done that before and, I know 17 I speak for everyone here, we found that very helpful. 18 If the witnesses are happy, certainly we would be helped 19 by it. If there are any difficulties for those who look 20 after us by taking the transcript, then I hope that they 21 will be able to indicate to me at any given moment so 22 that we can orchestrate it or choreograph it 23 appropriately. 24 MISS GREY: Perhaps they might both come up. We have been 25 asking for evidence to be given on oath or affirmation, 0001 1 so perhaps I could start by asking Mrs Jenkins, please, 2 to stand whilst she affirms. 3 MRS LIZ JENKINS (AFFIRMED) 4 MISS SUE BURR (AFFIRMED) 5 Examined by MISS GREY: 6 Q. First of all, I have introduced very briefly Miss Burr 7 and Mrs Jenkins, but I think you prefer to be called for 8 today's purposes Liz and Sue, if that is all right. 9 Perhaps I might ask Liz then first, you are the 10 Assistant General Secretary of the RCN now but perhaps 11 I might ask you to help us a little bit further with 12 your background and qualifications in this field because 13 I think you have very extensive experience firstly as 14 a nurse working within an adult renal unit giving 15 dialysis to both children and adults over a considerable 16 period of time. 17 MRS JENKINS: Yes, that is correct. I qualified at 18 St Thomas's Hospital back in 1965, between 1965 and 19 1968, and I went to work in the Guy's renal unit when it 20 was very much a pioneering renal unit for adults have 21 also for children. As an experienced dialysis nurse 22 after a few years, it seemed not strange to me that we 23 were looking after children because of course there was 24 nowhere else for them to go. 25 Q. It was seen not strange? 0002 1 A. It seems perfectly acceptable to be looking after 2 children because they were sick and we had the expertise 3 and skill and it never struck me as strange. 4 I had been there quite some time when we had an 5 appointment made to the consultant team of a paediatric 6 nephrologist, and he worked very closely with me and 7 these children and very quickly persuaded me that it 8 would be right and proper to employ nurses who were 9 RSCNs. 10 My initial response was that there were not 11 children's nurses in those days who were real experts, 12 because we were the only ones in the country, so we 13 agreed to bring nurses over from Great Ormond Street and 14 train them to be renal nurses. 15 All I can say to the Panel is what I saw as 16 a result of that was really quite extraordinary. I saw 17 the physical health, the mental health, the 18 psychological health of those children change quite 19 dramatically, and I became from that moment on a firm 20 believer that wherever children were looked after, 21 children's nurses undoubtedly made an enormous 22 difference. 23 Q. What period of time was it that you started to train 24 nurses? 25 A. I would have to look it up to be quite precise, but 0003 1 it will have been around the early 1980s/mid-1980s. 2 Q. You remained at the renal unit until about 1985, 3 I think, when you went to Westminster Hospital and 4 Westminster Children's Hospital as the Assistant 5 Director of Nursing; is that right? 6 A. Yes, that is correct. 7 Q. And from there, I think it is right to say that you 8 went to St Thomas's, where you were appointed the 9 Director of Nursing in about 1987? 10 A. That is correct. 11 Q. And from there, what happened to you next? 12 A. About 6 months after I went to St Thomas's, they were 13 appointing for the first General Manager of the 14 hospital, and I was persuaded by colleagues that if 15 I believed as passionately as I did about nursing and 16 the need to have nursing at the top voice of larger 17 hospitals, I should apply for the job. 18 Q. So you were made General Manager, the first General 19 Manager, of St Thomas's? 20 A. That is correct. 21 Q. Where you were responsible for the management not merely 22 of nurses but of doctors as well? 23 A. That is correct. 24 Q. How was that perceived in the hospital as a whole at 25 that time? 0004 1 A. I think it would be true to say that it was difficult. 2 Doctors had never seen themselves as responsible to any 3 one particular person in that era. Finding themselves 4 responsible to what they perceived as a young woman was 5 quite a shock. The fact I was a nurse and had trained 6 at their hospital was probably the surviving factor for 7 it. 8 Q. You survived sufficiently well to be appointed in about 9 1992 the Director of Nursing and Quality, where I think 10 you must have had responsibility for quality assurance 11 programmes and audit, some forms of audit, throughout 12 the hospital? 13 A. That is correct, including what was then actually 14 medical audit, before clinical audit overtook both 15 nursing and medical audit. 16 Q. It was from there in about 1995 that you moved to the 17 Royal College of Nursing initially as the Director of 18 Nursing Policy and Practice, and latterly as the 19 Assistant General Secretary? 20 A. That is correct. 21 Q. If I could then turn, please, to Sue Burr, you are, of 22 course at the moment the Paediatric Nursing Adviser to 23 the Royal College of Nursing, but you have again a very 24 extensive background in this field. In particular, 25 I think it is right to say that your experience has led 0005 1 to recognition in a number of respects. In 1991 you 2 were appointed a Florence Nightingale scholar and in 3 1993 you were the first paediatric nurse to be elected 4 a Fellow of The Royal College of Nursing. 5 In 1994 you were the first nurse to be elected an 6 Honorary Member of the British Paediatric Association as 7 it then was and when that later became the Royal College 8 of Paediatrics and Child Health you were elected 9 a Founding Fellow. 10 So I think it is fair to say that you have had 11 a very long history of involvement, indeed, in 12 paediatric nursing and a long concern for the voice of 13 children in nursing? 14 A. That is correct. 15 Q. I have attempted to summarise a CV that will be 16 available on the Internet very briefly, but is there 17 anything else you would like to add to that? 18 A. No. 19 Q. If we could turn, then, please, to WIT 42/1, this is the 20 statement which the Royal College of Nursing has very 21 kindly provided to the Inquiry, and there is the 22 covering letter from Christine Hancock, the General 23 Secretary. 24 If we turn to page 2, the statement itself 25 starts. I think there are just a small number of 0006 1 corrections that need first to be made to it. 2 If we could go to page 9 first, please, the first 3 sentence there I think needs a little correction, 4 is that right, in paragraph 3.3? 5 A. Yes. It should read: 6 "Nurse training for all branches of the register 7 was for three years duration for a first-level 8 qualification as a Registered Nurse." 9 Q. Rather "a Registered General Nurse"? 10 A. Correct. 11 Q. If we go on, please, to the rest of that paragraph, 12 again, could you just read the corrections, please? 13 A. It then goes on: 14 "... and a two year training for a second level 15 qualification as an enrolled nurse." 16 That is that, complete. 17 Q. So there is nothing else, I think, on paragraph 3.3, 18 but on paragraph 3.4, again there is a small correction 19 there? 20 A. Yes. It should read: 21 "The UKCC has closed new entry to the enrolled 22 nurse training programme. The only current training for 23 nursing leads, on successful completion, to registration 24 as a registered nurse." 25 Q. Then paragraph 3.7? 0007 1 A. That should read: 2 "The first Department of Health publicity 3 material..." 4 Q. So that is really just a typographical error there? 5 A. Yes. 6 Q. And the same again, a typographical error on 7 paragraph 4.10, which is to be found at page 13 of the 8 statement, please? 9 A. The last bullet point should read "and the environment 10 to be furnished". 11 Q. Thank you. 12 A. In the paragraph immediately under that, the second 13 line, it should read "professionally accountable to 14 a senior nurse". 15 Q. At page 14, paragraph 4.21, at page 15, please? 16 A. That should say that "the House of Commons Select 17 Committee made the following overall conclusions", not 18 "recommendations". 19 Q. If we turn over, please, to paragraph 7.5, page 22? 20 A. The last sentence should read: 21 "Concern has also been expressed, that support for 22 parents in becoming involved in the child's care is not 23 always available." 24 Q. And the last two corrections on paragraph 9.1, which 25 is to be found at page 24, please? 0008 1 A. The first sentence should read: 2 "The society is primarily concerned with general 3 paediatric nursing issues and links closely with other 4 RCN forums including those concerned with paediatric 5 nursing, school nursing, child protection and child and 6 young persons' mental health forums". 7 Q. Then finally at paragraph 12.7 at page 28, please? 8 A. That should read: 9 "Nurses can also raise their concerns through 10 forums, at Congress and at national conferences, and are 11 able to lobby and influence nationally." 12 MISS GREY: Thank you very much. Sir, we will put those 13 corrections formally out with the statement, but with 14 those amendments read into the transcript, are you 15 content that the evidence that has been submitted in 16 this statement -- we can see the last page of it, at 17 page 29, please, is true to the best of your knowledge, 18 information and belief? 19 MISS BURR: It is. 20 Q. Perhaps we could just start by examining in a little bit 21 more detail the role of the Royal College of Nursing 22 itself. If we turn to page 3 of the statement, please, 23 the statement gives us considerable detail about the 24 College. We are told in particular at paragraph 1.1 25 that it is the world's largest professional union of 0009 1 nurses, but that it is also a registered charity. 2 So it is a membership organisation composed of 3 nurses who are members part and parcel both of a charity 4 but also of a membership organisation. 5 How would you compare or contrast the structure 6 and functions of the RCN with those of, say, the British 7 Medical Association? 8 MISS JENKINS: I think the primary difference is that 9 the Royal College of Nursing is a membership 10 organisation, a charity, as you say, and also a trades 11 union. The BMA is, as far as I am aware, the Trade 12 Union for a group of doctors and of course the Medical 13 Royal Colleges act primarily as the professional body. 14 There is no doubt that the BMA undertakes some 15 professional work as well, but I think if you spoke to 16 many doctors about how they would see the difference 17 between the BMA and the Royal Colleges, they would make 18 that separation, whereas nurses view the Royal College 19 of Nursing in two separate ways. The truth is that most 20 of our members join the Royal College of Nursing in 21 order to be protected when they need protection, and 22 they may well not use the Royal College of Nursing for 23 anything very much else, other than that. 24 However, of our group of activists, the next 25 largest group of people who access the Royal College of 0010 1 Nursing, access it because they find that it gives them 2 networks, facilities, opportunities to advance their own 3 practice, to support them professionally and to promote 4 their particular work, so that the network of clinical 5 forums that we run are very, very -- one of our most 6 popular parts of our organisation. 7 Q. You speak of that further in the statement, where you 8 mention the fact that the RCN is a membership 9 organisation whilst the UKCC is the regulatory body, and 10 you go on to say -- I am looking at paragraph 1.4, if we 11 scroll up the page a little, that the UKCC guidance 12 reflects minimum standards of conduct and practice, 13 whilst the RCN guidance reflects the aim of the Charter 14 to enhance the science and art of nursing. 15 So you would see yourself as attempting to set 16 standards of best practice and to raise standards in 17 contrast to merely setting minimum standards? 18 A. Yes. I think this is quite a difficult thing to 19 describe in the Royal College of Nursing. We have no 20 statutory responsibility to insist on any level of 21 standards of care. However, what we do have is a very 22 passionate belief, and indeed, it is embodied in our 23 Royal Charter that one of our main roles is to promote 24 the science and art of nursing. 25 We do that through a variety of different ways: 0011 1 we run an academic institute where we educate people in 2 many, many post-graduate qualifications. We run 3 educational programmes and conferences which give nurses 4 professional educational points. We run this vast 5 series of membership what we call "forums" which allow 6 nurses in specialisms to not only network with their own 7 colleagues, but also have a Steering Committee which 8 will work with the Royal College Royal College of 9 Nursing and the specialist Nurse Advisers to set 10 standards, to develop guidelines and on many occasions 11 to directly lobby government for something that they 12 feel passionate about. 13 Q. Is there any tension between being a membership 14 organisation, a trade union, and being an organisation 15 that is concerned to lead its members in setting high 16 standards? 17 A. Yes, there is tension, but it is a dynamic and positive 18 tension; it very rarely is an area of conflict. In 19 fact, we believe very strongly that if you are working 20 in our boards and regions and representing a nurse who 21 may be in some difficulty, that you need to know as much 22 about the professional background of that nurse and what 23 is available for her through the Royal College of 24 Nursing as you do about her pay and conditions. 25 In other words, we do not believe that you can 0012 1 argue for the welfare of nurses without arguing for the 2 high standards of nursing care, and equally, we do not 3 believe that you can say nurses should practise high 4 standards of nursing care if at the same time you do not 5 value them and recognise them through their remuneration 6 in the same way. 7 So with those examples I have given, the two 8 sides, if you like, of our organisation work 9 extraordinarily powerfully together. 10 There are, of course, occasionally some tensions. 11 Some of our members believe we should be more of one 12 thing and some of our members believe we should be more 13 of the other. 14 Q. But you would say then you have not found it necessary 15 to be cautious in the standards or guidelines you have 16 set because of the need to reflect a professional 17 consensus that might represent the trailing edge of 18 practice rather than the cutting edge? 19 A. Because we are not in a position to enforce the 20 standards that our nurses set themselves, then, no, we 21 do not have that conflict, because we are not setting 22 those standards for them; we are working with them and 23 they set them themselves. Almost all of our 24 publications and documentation is member-led: there 25 will, of course, be times when staff, particularly those 0013 1 who are highly expert, will have a large role in working 2 with various groups, but we would never assume to expect 3 nurses to set standards that they themselves did not 4 feel that they could achieve. 5 Q. You mention again at paragraph 1.4 of this statement 6 that the UKCC has the power to remove members from the 7 Register of Nurses for misconduct. You also say that of 8 course the RCN itself can remove members from membership 9 of the RCN although this power has never been used. Can 10 you comment on the reasons for that? 11 A. Yes, I think I can. One of the reasons is because the 12 majority of nurses who get themselves into serious 13 trouble end up in front of the UKCC and if they are 14 found guilty of professional misconduct, they will be 15 removed from the UKCC register. You cannot be a member 16 of the RCN unless you are registered with the UKCC. 17 There could be times when a member of the RCN 18 brought the RCN into disrepute without necessarily being 19 guilty of professional misconduct, and should that 20 happen, our governing body, our Council, has the ability 21 to remove people from membership. 22 Q. In effect we need to add to the detail at 1.4 that if 23 the UKCC removes members from its register, then they 24 cease to be members of the RCN as well? 25 A. Yes. The only people who can be members of the RCN 0014 1 are qualified nurses or those who are actively 2 undertaking registration to be qualified, in other 3 words, are student nurses, and you have to be 4 a signed-up licensee of the UKCC. 5 Q. How would you say that the role of the RCN differs from 6 those of the Medical Royal Colleges? One obvious 7 contrast perhaps is that you do not have the role in the 8 training or accreditation of nurses that the Colleges 9 have in the training and accreditation of doctors. 10 Are there any other contrasts that you would like 11 to draw to the Panel's attention? 12 A. I think that you are absolutely right, that is probably 13 the clearest difference. The other difference is, of 14 course, the difference of doctors and nurses themselves 15 in that our medical colleagues, as they progress through 16 their career pathway, continue to hold a remit for 17 caring for patients; they have a clinical caseload, 18 whereas nurses in general, as they progress through 19 their careers, whether that is into education or 20 management, actually lose their clinical caseload. 21 We are now beginning to see a cadre of nurses who can 22 progress and we encourage it, who can progress 23 reasonably high up the clinical career path, who can 24 retain a clinical caseload. 25 So perhaps one of the differences is that the most 0015 1 senior people within the Medical Royal Colleges will be 2 people who are actively still seeing patients, whereas 3 that would be slightly different for some of our senior 4 members. 5 Q. Perhaps one of the other differences is simply that the 6 Royal Colleges would not have an explicit Trade Union 7 function, which of course the RCN does? 8 A. Yes, and I do reiterate that we see that as a very 9 definite strength, because within our one organisation, 10 we are able to not only look after the welfare of our 11 members, but at the same time, if you like, the welfare 12 of the public by promoting standards of care through 13 promoting the science and art of nursing. 14 Q. In hearing evidence from the Royal Colleges in 15 particular, we have heard a great deal about the 16 national agenda at present and in particular, about the 17 role of continuing professional development and 18 continuing professional education. 19 Can I expand perhaps a little on the topical 20 issues of concern to nurses on that particular agenda? 21 If we look at page 5 of the statement at paragraph 1.12, 22 we can see there briefly some of the issues that are 23 obviously of concern to the RCN at present, but perhaps 24 you could just help us a little on what might be the key 25 topical issues for the development of nursing at 0016 1 present? 2 A. I do not think that there is any doubt that clinical 3 governance is probably the most major aspect for nurses 4 at the moment, mainly because it gives them so many 5 opportunities that they may not always have felt they 6 have had before. If I can go back a little bit, we 7 believe that nurses have been perhaps more involved with 8 and interested in the quality of care that their 9 patients get in a holistic way for rather longer than 10 some of our other professional colleagues. I do not 11 pretend that it was particularly sophisticated back 12 in -- I am talking about the early 1970s, through the 13 1970s and even the early 1980s, but you would find, if 14 it had been properly documented, that there were nurses 15 working on improving what they were doing in many areas 16 of the country, long before it was being talked about. 17 Nursing audit, which is mentioned here, then 18 became, I was going to say "fashionable", but it became 19 recognised as a tool that nurses could use to improve 20 things, and that very quickly, particularly with the 21 RCN's work on standard-setting, what is known as our 22 "dynamic standard setting system", gained enormous 23 credence in the late 1980s and early 90s, but nursing 24 audit very quickly and I think quite rightly got 25 subsumed into clinical audit, so nurses now feel that 0017 1 the agenda that is set with clinical governance does 2 give them the opportunities, or should give them the 3 opportunities not only to improve patient care, but to 4 be involved in the decisions that are made about how 5 care is delivered, where care is delivered, and who 6 delivers it. 7 Q. I think I saw you nodding there, Sue. Is there 8 anything you would like to add to that? 9 MISS BURR: If I could just give an example, yesterday the 10 paediatric intensive care nurses were meeting and 11 discussing their own standards produced in 1994 and they 12 were actually seeing the difficulty of having those 13 implemented in their own units because obviously those 14 involved in writing them are at the leading edge of 15 nursing and it does not necessarily mean that their 16 units are going to implement the guidance, but they felt 17 there was a distinct move with clinical governance that 18 they were for the first time really going to be involved 19 and that the standards that they had previously written 20 were going to be taken on board and they actually felt 21 now they were going to have a voice that they have not 22 had previously; obviously they had in some excellent 23 units, but as a generalisation, clinical governance was 24 going to make a big difference to them. 25 Q. Thank you. I think that touches on a number of themes 0018 1 we will perhaps explore in a little more detail 2 throughout this morning, but perhaps for the moment 3 I could turn to page 7 of the RCN statement, where you 4 set out a very helpful historical perspective on health 5 services for children. 6 This is a perspective which in fact was already 7 put to Professor Baum of the Royal College of 8 Paediatrics and Child Health, and he already has 9 endorsed it as being a statement or perspective with 10 which he would broadly agree. 11 Can I ask you to help us a little bit further on 12 some aspects of it. 13 If we look at paragraph 2.6 of the statement, we 14 need to turn over the page, please, where generally the 15 statement makes the point that there have been 16 difficulties in establishing a true recognition of the 17 status and value of child health professionals. 18 Can you help us, what would you say was the 19 position across the period in 1984 to 1995 if we measure 20 that period against this gradual evolution in the status 21 of child health professionals. 22 MISS BURR: I think the medical staff are not that much 23 different to the nursing staff, but there was a gradual 24 recognition of the needs of children. The period is 25 quite interesting, because as you will note, it was the 0019 1 first time the Royal College of Nursing appointed 2 a Paediatric Nurse Adviser, and we were the last branch 3 of nursing to be formally recognised within the Royal 4 College. 5 Hopefully, during the last 15 years, the 6 opportunity for children's nurses to promote the needs 7 of children has meant that the recognition of the 8 special needs of children and the nurses to care for 9 them has been more widely recognised. 10 There have of course been other things in the 11 wider social context, if you like, the United Nations 12 Convention on the Rights of the Child; in England and 13 Wales the Children Act of 1989; in Scotland, the 14 Children (Scotland)Act 1995; and the Northern Ireland 15 (Children)Order in 1995 too. So there have been things in the 16 social context of people recognising perhaps the 17 vulnerability of children, as well as within the nursing 18 profession. 19 The Royal College of Nursing, of course, only 20 represents really society as a whole, and so the fact 21 that children's nurses have felt that they have had 22 difficulty getting the voice of children and children's 23 nurses heard within their Royal College only reflects 24 the difficulty that they have within society as a whole. 25 Q. You mention that the Paediatric Nurse Adviser was first 0020 1 appointed in 1984, right at the beginning of our 2 period. What was the role envisaged for that officer 3 when he or she was first appointed? 4 A. I am not sure what it was. I was that person, and 5 still am the first Paediatric Nurse Adviser to the 6 College. If you like, I had an amazing opportunity 7 because to some extent -- and Miss Jenkins was involved 8 in my appointment -- I have been given the opportunity 9 to develop networks particularly for the nurses and 10 I think a lot of it is identifying opportunities to make 11 sure that the voice of children is heard. That is not 12 only in governmental situations, where, for example, 13 even today there is a National Service framework in 14 relation to mental health but it does not include 15 children, although child and adolescent mental health is 16 one of the government priorities and to contact the 17 relevant people and say why are the people not involved, 18 as well as in College publications where we still have 19 situations and publications are produced which include 20 children but in fact have not been near any children's 21 nurses, and in fact do not represent appropriate care 22 for children. 23 So there is this difficulty of having things that 24 tend to be all-inclusive rather than actually stating 25 "this does not involve children", or doing something 0021 1 separate for them. 2 But certainly people would say that having 3 a Paediatric Nurse Adviser post within the Royal College 4 of Nursing has made a tremendous difference to 5 children's nurses. Obviously that is a little difficult 6 for me to say because I am that person. The fact that 7 I was asked in a personal capacity to be a specialist 8 adviser to the House of Commons Select Committee and, 9 three years ago now, was awarded an OBE for children's 10 nursing. I would not have had the opportunity to do 11 those things for children's nursing if the Royal College 12 of Nursing had not appointed a paediatric nurse. 13 One of the things further down is to recognise 14 the difficulty of getting the children's nurse and the 15 children's nurse's voice heard, whether it is 16 a professional, governmental or statutory bodies, 17 because often they are not represented at those levels. 18 Q. If RSCNs or nurses who have completed the child branch 19 of Project 2000 form only a small part of the nursing 20 workforce, how successful do you think the RCN has been 21 at representing those children's nurses? 22 A. I am not aware that any of our members have felt that 23 they have not been represented appropriately. I think 24 that shows some of the advantages of College, although 25 the members might be represented at a local level by our 0022 1 regional officers, because, as with all specialist 2 advisers, they can contact me, I can read the papers, 3 I can suggest ways of helping them, et cetera. 4 Certainly my feedback from members is that the 5 children's nurses feel well represented by Royal College 6 of Nursing staff, because there are people with 7 different skills and experiences to be able to pull 8 together because we are all in one organisation, to 9 actually -- we can put together the most amazing amount 10 of expertise from our staff, and also utilising other 11 members. 12 MRS JENKINS: Can I just add to that, please? The role 13 of an adviser is usually for an area of specialist 14 nursing; it may not always be a whole branch of nursing 15 like paediatrics; it may be a specialism like cancer 16 nursing and the role of the adviser is to raise 17 standards of practice, develop policies which both 18 assist the nurses themselves to provide better care for 19 their patients, but also to develop policies which 20 change the practice for the country, for the nation. 21 They also link in with our educational programmes 22 within the institute and link in with our research work, 23 but overall the role of an adviser is to draw together 24 all those strands, and somehow get it out into 25 Hartlepool, Halifax and Hereford. 0023 1 I have to say in paediatric nursing, without 2 mentioning any names, we have clearly been extremely 3 successful because not only do we have a very large 4 Paediatric Nursing Society, but I think I am right in 5 saying some 15 other paediatric specialist membership 6 groups. So a nurse who works in the community looking 7 after children on ventilators knows that she can come 8 and meet other people who do the same thing. 9 So within the paediatric world of nurses, which is 10 in a way quite a small world, I think we would see that 11 the large majority of them were linked in to one of or 12 paediatric forums and they have, as a group of members, 13 been very active in lobbying those of us at the Royal 14 College of Nursing who are in senior positions for more 15 resources for their various forums. 16 MISS BURR: If I could just add to that too, I think the 17 facility the Royal College of Nursing has to disseminate 18 information and good practice has been extraordinarily 19 helpful to children's nurses. Whether that is in 20 relation to guidance that has been issued by the 21 Department of Health and which their managers are not 22 aware of and therefore they can use those as tools to 23 improve the care of the children, but also in relation 24 to our own Journal of Paediatric Nursing which has been 25 extraordinarily successful, having the biggest 0024 1 circulation of any specialist journal. 2 Q. One of the aspects of the failure to recognise or 3 difficulties in achieving recognition of children's 4 specialities that you discussed in your statement has 5 been a shortage of qualified RSCNs, or children's nurses 6 more generally. 7 I do not want, unless you would like me to, to go 8 over the details of the reports that have made this 9 point throughout our period; it has been repeated 10 often. What I would like to explore with you a little 11 is the reasons why that might be so, and in particular, 12 the responses that an institution might make to 13 a shortage of RSCNs. 14 If we turn to page 18 of your statement, you 15 summarise there the 1993 Audit Commission report, 16 "Children First" and at paragraph 49 you set out the 17 Audit Commission's finding that there were two reasons 18 for the scarcity of RSCNs, firstly that managers 19 frequently did not perceive the need for them, and 20 secondly, "the lack of prospects for care development in 21 sick children's nursing and the low status of the work 22 as perceived by nurses in general." 23 Is that a comment or finding that accords with 24 your experience? 25 A. Absolutely. If I could just add slightly to that? The 0025 1 fact that Beverley Allitt, the other wards in the 2 hospital would not employ her so she was sent to the 3 children's ward. I have to say that obviously what she 4 undertook was uncommon, but the fact that they sent 5 somebody nobody else wanted to the children's ward is 6 not uncommon. 7 Q. If we come to some of the evidence we have been hearing 8 about Ward 5, the cardiac ward in Bristol, that was of 9 course a mixed adult and children's ward dealing with 10 a cardiac specialty. One of the pieces or strands of 11 evidence we have heard has been that it was difficult to 12 recruit or to retain RSCNs because they did not want to 13 work with adults; they wanted to work with children. 14 Is that something that would again accord with 15 your experience? 16 A. Yes. That would go to other settings such as accident 17 and emergency where there are children and adults. The 18 important thing is that the nurses feel that they are 19 valued for the skills that they have and that they have 20 access to and networks with other paediatric nurses. 21 Q. Because it may not be as simple as merely saying, "We 22 want to work with children". There may be other strands 23 in the unwillingness to work in a mixed ward that you 24 are beginning to touch upon in your answer. Can you 25 just develop that a little further? 0026 1 A. If you are working in what might be called a mixed unit, 2 but is actually a very much adult-focused unit, it means 3 that even something as simple as getting an appropriate 4 milk ration for the children or child-sized operation 5 gowns can be quite an event and I am afraid that often 6 senior people may think "It is those children's 7 nurses" -- said to me very commonly -- "they always want 8 something different". Of course they want something 9 different because their client group are very different 10 to the main focus of care which is for adults, so 11 everything tends to be a fight, whether it is for 12 equipment or play staff or whatever. That can be very 13 wearing in what is already a very difficult situation, 14 particularly if they are working in intensive care. 15 I think there is also a concern sometimes 16 career-wise that if they are in that situation and they 17 wish to progress into children's nurses they have got 18 themselves into a bit of a cul-de-sac if they do not 19 have the networks into the paediatric side and 20 certainly, in relation to getting nursing advice in 21 relation to the children, where do they get that from if 22 they do not have any professional line to a senior 23 children's nurse? 24 I think that is a major problem, if they do not 25 have a professional line to the senior children's nurse. 0027 1 Q. If we could just remain with the first part of your 2 answer for a moment, the part in which you talked about 3 it being a fight to achieve standards or equipment that 4 were appropriate for children, is that part of what you 5 have reflected at paragraph 3.5 of the statement -- this 6 is at page 9. If we flick back to that, we see there 7 a reference to studies by academics such as Hutt. Is 8 that what you were talking about? 9 A. Exactly. There are things like the other staff. If you 10 are in what is mainly focused on children, then most of 11 the staff, whether you are talking about cleaning staff 12 or portering staff, they work there because they like 13 working for children. Everything is geared towards the 14 child and their family, so if you ask for things, 15 whether it is a highchair or paediatric resuscitation 16 equipment to take it from things for daily living to 17 things for clinical need, there is no fight about it. 18 It is just accepted that that is what you need to 19 provide an appropriate standard of care. And the whole 20 atmosphere is geared towards the needs of the children 21 and their families, whereas, if you are working in what 22 is an adult focus and you do not have management who 23 really understand the needs of the children, everything 24 is a fight. 25 Q. Moving to the second part of your answer, you were 0028 1 talking about the gauge of being put into a professional 2 "siding", as it were, and difficulties of maintaining 3 skills if you did not have access to a Paediatric Nurse 4 Adviser, or colleague who was able to provide 5 assistance. 6 That, I think, leads on to the question I was 7 asking you initially, which is, if you had difficulty 8 recruiting or retaining RSCNs because you were working 9 in a specialty ward rather than a children's ward, what 10 is the appropriate response by management to that 11 difficulty? 12 A. To start with, obviously I think management need to talk 13 with the nurses about their professional development and 14 what opportunities are available to them, and then what 15 is happening -- we went through a period where it 16 happened quite a lot, and then, in relation to some of 17 the competition with Trusts that tended to be more 18 difficult and now it is actually expanding again. Where 19 nurses can go to visit other units there may be 20 exchanges. They are invited into the educational 21 opportunities that are put on, whether that is 22 in-service training, whether in relation to the general 23 needs of the child -- because, you know, the child is 24 a child; it is not just a child that has a heart anomaly 25 that is having surgery. 0029 1 I think one of the other difficulties, if you are 2 in something which is very specialist, is that you tend 3 to view children as just "that kind of child" and you 4 forget about their emotional and physical development. 5 It is important to think of the child as a whole and as 6 part of a family and part of that community. Of course, 7 that is much more difficult to do if you are on 8 a totally adult focus. 9 So the Manager should be involving them. The 10 protocols and policies should be the same for 11 a children's unit for the care of the children in what 12 might be an adult focused unit. 13 MRS JENKINS: Can I just jump in there and say that I think 14 there are often times where a specialist unit in 15 a hospital may have some staffing difficulties. One of 16 the ways that I think managers can get around this -- we 17 certainly again did it in the renal unit at Guy's 18 Hospital -- was to rotate nurses through the various 19 parts of the unit, so, for instance, in my experience 20 there were a group of nurses who thought dialysing 21 patients was the only thing they want to do and they 22 became very expert at it, but they did not then 23 understand about what happened to their patients when 24 they got transplanted. So we would move people around. 25 You cannot do that to nurses if they are feeling 0030 1 forced into doing it, but certainly, if I was running an 2 organisation where paediatric nurses were impossible to 3 get hold of for whatever reason, I would do two things: 4 I would firstly want to look at why I was having 5 difficulty in recruiting them and that might just be 6 that there is a world shortage of that particular 7 specialty, although I have to say I think there are 8 other reasons why I think sometimes recruitment is 9 difficult and I would like to touch on that at some 10 stage. 11 The second thing I would do is: (a) ensure that 12 you moved nurses from your children's areas to the adult 13 intensive care unit so they would know what their 14 patients were going through when they went there; and 15 (b) ensure that you have a constant flow of expertise 16 that you can then tackle. 17 Q. What are the difficulties of achieving that? Why might 18 such a programme start but founder or only be 19 implemented sporadically? 20 A. I think lack of determination of those people trying 21 to provide the services, or lack of understanding of 22 what it is you are trying to do. So, for instance, if 23 you were rotating nurses from your children's ward or 24 your children's hospital into an adult area, and every 25 time you did it they were unwelcomed, undervalued, made 0031 1 to feel that they were a nuisance, then you will find 2 that it will founder. 3 One of the most interesting pieces of work 4 I think that has been undertaken in nursing in the last 5 ten years is some work out of North America about what 6 we call "magnet" hospitals, and I would like to briefly 7 describe a magnet hospital. 8 The American Nurses Association noticed across the 9 US there were about 15 major hospitals where nurses 10 really wanted to go and work. They would wait years to 11 get a job there. They would move city to go and work in 12 them. They describe them as "magnets". They were 13 clearly magnets to nurses. 14 They then decided they needed to find out why 15 these places were so attractive and what it was about 16 them that made nurses want to go there. What they 17 discovered was that the indicators they came out with 18 were that there was low turnover of nurses, nurses 19 participated in the management of the organisation, 20 there were strong nurse leaders; the nurses themselves 21 were given autonomy and accountability to make decisions 22 about the delivery of the care. The nurses were 23 involved in the Hospital Executive. They had reasonably 24 good staffing levels and they were encouraged to 25 undertake professional development and career work. 0032 1 About 15 years later they matched those -- I think 2 it was 15 hospitals -- against about 75 other hospitals 3 which were exactly the same but were not magnets and 4 they demonstrated that mortality rates were lower, 5 patients got out of hospital quicker, patients were more 6 inclined to stick with their medical regimens. 7 So we have evidence which shows where nurses are 8 respected, treated with value and allowed to make 9 decisions about their client group and paediatric nurses 10 could not be a better example because they know how to 11 look after children in a way other nurses do not, then 12 I think there are mechanisms by which managers can make 13 it easier to recruit and retain even the most 14 "gold-dust" of nurses, where there may not be many of 15 them. 16 MISS BURR: I would totally support what Liz says. 17 Q. Can I ask, if you were encountering, across the late 18 1980s or early 1990s, a unit which had difficulty in 19 achieving or maintaining a rotation programme in its 20 single specialty wards, would you regard that as being 21 something which was an all too common experience across 22 the UK or would that be something that was unusual? How 23 often were the aspirations you have described achieved 24 in practice? 25 MRS JENKINS: I would think it would be fair to say that it 0033 1 was probably not that easy, and the reason for what 2 makes a good unit in any hospital is some element of 3 a variety of different things. Units that I have come 4 across where nurses are happiest and feel that what they 5 are doing for their patients is as good as they would 6 like it to be, are almost without exception units that 7 have strong nursing leadership, where doctors and nurses 8 and other professionals work very closely together and 9 decisions about patient care are shared, which gives 10 that team of people an amazing feeling of ability to 11 change things because they are listened to. So if you 12 are trying to rotate people through two different areas 13 where in one area they may not feel valued and indeed 14 the people they are being rotated into do not think 15 there is any reason for them being there, and if the 16 management is not passionate about what you are doing, 17 then it will not work. 18 I have tried rotating nurses in all sorts of areas 19 and sometimes it simply does not work. Nurses do like 20 to work with the client group they want to work with. 21 They can make it quite difficult if you want to try and 22 put them somewhere else, unless it is a crisis. 23 Q. Perhaps I might ask you to go back to something you 24 indicated you would like to touch upon, which was the 25 issue of recruitment of RSCNs, because you hinted 0034 1 I think a few moments ago that you would see other 2 factors as being more important than the national 3 shortage of these sorts of skills? 4 A. I think only to reiterate the type of thing I have just 5 said. Sue spoke earlier about, if you like, the 6 paediatric nursing and indeed children not being heard. 7 I think this is very real. If you have worked with 8 children's nurses or children, then it is quite clear 9 that, you know, you will know how real these issues are, 10 but I do think that the majority of adult qualified 11 nurses and doctors see children as small adults, who 12 simply need smaller beds and smaller portions of food. 13 They do not see them as a client group that have wholly 14 different needs. 15 So I think that the recruitment and retention of 16 paediatric nurses is not because it is a specialism that 17 nurses do not wish to undertake, because actually 18 I think it is a specialism that many nurses want to 19 undertake, but first of all, and Sue, I think, will need 20 to just clarify what I am about to say, going back to 21 the early to mid-1980s, you had to have undertaken an 22 adult training usually before you could become 23 a paediatric nurse, has to be something that must have 24 put many people off who wanted to be a children's 25 nurse. Secondly, if, then, when you are doing it, you 0035 1 do not feel that the work you are doing is particularly 2 highly valued, then you might find that your recruitment 3 and your retention is poor. 4 I just want to make sure I am correct -- I may not 5 be quite correct in those figures. 6 MISS BURR: I undertook a three-year children's training and 7 it was made quite clear to us that unless you did adult 8 training the likelihood of promotion was very small, 9 although if you take other areas of nursing, it really 10 was quite common in those days to expect female nurses 11 to have adult nursing and midwifery, and male nurses 12 adult nursing and mental health. That was around as 13 well, so there are other factors there. 14 I think the research that was done prior to the 15 Briggs report showed that there were at that time -- and 16 we have no reason to think it is different now from the 17 popularity of the child branch -- a substantial number 18 of people who wish to nurse children who are not keen to 19 undertake three-year training in nursing adults prior to 20 then specialising in children. 21 I did my general training. I have never ever 22 worked in a ward -- other than a few weeks after 23 registration -- as an adult nurse with adults; I went 24 back to children's nursing. I have always found it 25 quite fascinating how people will select out my 0036 1 Registered General Nurse training, which actually only 2 took 18 months, against my three years of children's 3 training, and they do not refer to your children's 4 qualification, although that is what I have used mostly 5 for the whole of my professional life. 6 So there is that status scenario, too. 7 MRS JENKINS: Can I add something there I have just 8 thought of? One of the things we also do not tend to 9 do, when we are advertising for senior nursing posts, we 10 will advertise for a Registered General Nurse, and 11 I have to tell you that it was Sue who berated me after 12 I had been in post for about two years and I advertised, 13 I cannot remember what for, an adviser in something or 14 other, and she said "Why on earth did you not state in 15 this advert that this job could have been done perfectly 16 well by somebody who had a children's qualification?" 17 I am afraid those of us who are adult general nurses do 18 not think like that. We simply think that is the 19 gateway to all senior posts. It is those sorts of 20 things which make paediatric nurses feel undermined. 21 Q. If we look at some of the evidence we have received so 22 far about the staffing levels of the RSCNs on Ward 5, 23 we have heard recently that there were two RSCN nurses 24 on Ward 5's complement. There was an F grade who worked 25 in both the intensive care unit and the ward area, and 0037 1 another RSCN who worked in the nursery. That was where 2 children moved after they had been in the ITU section -- 3 there was no high dependency unit so they went straight 4 to the nursery when they were sufficiently well. She 5 was based in the nursery. 6 We were also told that the F grade RSCN would 7 always work on the intensive care unit on a Tuesday and 8 a Thursday late shift, because those were the days in 9 which the majority of the children's big cases were done 10 in those days, and that the other RSCN who worked in the 11 nursery was a newly qualified paediatric trained nurse. 12 She had done no adult training so all her training was 13 in paediatrics and she was employed to work in the 14 nursery because she did not have the experience of any 15 intensive care to work in the ITU. 16 That evidence related to the period broadly 17 around 1993 when the person giving it was the Clinical 18 Nurse Manager, and if we could bring up, perhaps on the 19 screen, the document HOME 2/21, this is part of the 20 Department of Health guidelines, Welfare of Children in 21 Hospital. If we go to paragraph 3.3.3 at the bottom, we 22 can see: 23 "Whether the service is to be provided in discrete 24 children's units or in a designated area within an adult 25 ICU", which is what we are dealing with here, "... there 0038 1 should be the following standards for paediatric 2 intensive care..." 3 We are told there should be a nurse in charge with 4 an RSCN qualification and then other standards are set 5 out. 6 How does the situation I have just described 7 compare to those standards or guidelines or other 8 current ones that you wish to rely upon? 9 THE CHAIRMAN: Miss Grey, just before the witness's answer, 10 you referred to "Ward 5". It is clear we are talking 11 about the BRI there, just for the sake of clarity. 12 MISS GREY: Thank you. 13 MISS BURR: I think the pertinent word is the nurse in 14 charge is a registered "children's" nurse, and in 15 relation to the Ward 5 situation, what I find very sad 16 is that there was a paediatric intensive care unit at 17 the Children's Hospital and it is to me sad that the 18 senior nurse for the Children's Hospital did not have 19 input into Ward 5 and that there was, as is referred to 20 earlier, some rotation of staff, that they shared 21 policies and protocols; documentation for the children 22 was the same. 23 So in fact, although there was a separation of 24 sites and they were not able to employ sufficiently 25 children's nurses to meet government recommendations, 0039 1 that they were working towards children's nurses having 2 a real input into that ward and the expertise of 3 children's nurses "up the hill", if you like, was 4 involved in the care of those children, as some of those 5 children did then go to the Children's Hospital. 6 I think that for the families, they did not see this as 7 a continuous service; they felt that they were going to 8 another place. 9 Q. It may be that we will hear more about the attempts 10 that were made or initiatives to achieve some continuity 11 or linkage between the two sites, but if the situation 12 that I described is accurate, can you help us by putting 13 that into the national context at the time? 14 A. Obviously I do not have access to the staffing levels of 15 paediatric intensive care. I would not have thought 16 that that was uncommon, and in fact we do have 17 situations, and you have the evidence, I am sure, in 18 relation to the number of children who are nursed even 19 now in adult intensive care units and I think one of the 20 quite recent reports showed that there was a large 21 number of these units which did not employ any 22 registered children's nurses at all. So I do not think 23 the situation in the BRI was that uncommon. 24 Q. To what extent would the absence of an RSCN 25 qualification be capable of being supplemented, or the 0040 1 difference not be important because of other forms of 2 training? I am thinking of the ENB 415, or possibly 3 in-house training? 4 A. I think the important thing about being an RSCN is that 5 it is your foundation, so if you are going to be either 6 an adult nurse or a children's nurse you do a foundation 7 course about the child as a whole in relation to the 8 family and society, and then on top of that, you build 9 your specialty, whether that is intensive care, cancer 10 nursing or whatever, but you view the patient as a child 11 and everything that goes with it. 12 The difficulty is if you have done an adult 13 nursing course and then go on to do some additional 14 training, whether in-service or an ENB course in 15 relation to a specialty. Obviously that is concentrated 16 on the techniques, particularly, but the particular 17 knowledge and skills for that specialty rather than as 18 a child. 19 Liz and I were just talking the other day, my 20 mind is set that I automatically look at things thinking 21 "How does the child fit into here?" Obviously I am not 22 thinking about the specialty. Even if I am looking at 23 oncology, I am not thinking about specific paediatric 24 oncology, I am thinking about the child. If you have 25 not undertaken children's training, I think that is much 0041 1 more difficult to do. 2 MISS GREY: Thank you. I wonder if that might be 3 a convenient moment to break, sir? 4 THE CHAIRMAN: Yes. Thank you, Miss Grey. Shall we take 5 a 15 minute break and reconvene at 11 o'clock? 6 (10.45 am) 7 (A short break) 8 (11.00 am) 9 MISS GREY: Sir, before the break I was asking questions 10 about staffing recruitment. If we could turn to the 11 slightly different issue of the guidance that has been 12 promoted about children's services over the years, you 13 deal with this in some detail at page 25 of the 14 statement, paragraph 11. [WIT 42/25] Could we go to 15 page 16, please, of the statement? [WIT 42/16]. You 16 talk about having set out the history of guidance and 17 any guidance or guidelines that exist in the area. 18 If we go to the bottom of the page, you talk about 19 the failure to implement guidance in the area over the 20 years. 21 I think if I can summarise what appears to emerge 22 from the statement, it is this: that there are many good 23 and potentially effective guidelines in the children's 24 areas in the view of the Royal College of Nursing, and 25 that in particular, for instance, there is much that has 0042 1 been said as early as the Platt report and then 2 reiterated many times about the need for a child-centred 3 approach, and therefore, it follows from that, the 4 preference for nursing on children's wards, but that 5 there have been problems in that firstly you mention, 6 over the page -- I am looking at page 17, therefore -- 7 there have been repeated problems in disseminating 8 guidelines and in co-ordinating their distribution 9 throughout the NHS, but that more fundamentally, the 10 guidance that has not been made mandatory and has 11 therefore not been followed. 12 Is that a fair summary of the thrust of the 13 evidence given by the College in this field? 14 MISS BURR: Correct. 15 Q. Can you tell us what you think the reasons for the 16 failure to make guidance mandatory or to achieve greater 17 progress in the area have been over the years? 18 A. I think, as the Audit Commission said, there is 19 a failure of management to actually acknowledge that it 20 is important because they do not have an appropriate 21 insight into the different needs of children and their 22 families. A very common thing that is used is expense, 23 I have to say, and certainly the Audit Commission bore 24 that out, but often it is not about expense, it is about 25 attitude and often you can improve the care of the 0043 1 children considerably by just reorganising the 2 facilities and the finances you have at the present 3 time, and in fact, in some situations you can actually 4 save money. 5 It is really this failure to acknowledge that 6 children's services are different and that children are 7 any different than an adult, other than that you need 8 smaller things, as was referred to earlier. 9 The other thing that has happened more recently 10 as units have involved families more, we have 11 a difficulty now where often a non-children's Nurse 12 Manager will say "Because there are parents on the ward 13 you do not need any nurses", which shows they have 14 absolutely no insight into the purpose of having parents 15 there. One of the main reasons is so that the families 16 can participate in the care of the child so that they 17 are confident and competent to care for their child to 18 facilitate early discharge. So although you may need 19 less bodies, you actually need a richer skill mix 20 because every family is individual and how an individual 21 parent reacts to their child's illness and how they are 22 able to take on an aspect of care varies tremendously, 23 so you need the nurse to pick up those cues, support the 24 families and educate them. It is not just if the 25 families feel confident. If the child is old enough it 0044 1 is very important that the child feels that the family 2 member who is going to care for them at home is 3 confident in what they are doing as well. 4 I have forgotten the question now! 5 Q. I was asking why it was in your opinion there had been 6 no further progress in implementing guidelines or making 7 them mandatory? 8 A. I think the senior management scenario is that it is 9 very difficult for children's nurses to be in that 10 senior management area, so if you are not involved in 11 the policy making and you do not have the authority to 12 implement things because the people who do have that 13 authority do not think they are important, then it is 14 not going to happen. And the successive governments 15 have not felt that it was appropriate for them to make 16 the guidance mandatory. 17 I have to say that the present government, with 18 the paediatric intensive care guidance that came out in 19 July 1997, we were absolutely delighted that for the 20 very first time it did give some time period by which 21 they would expect their recommendations to be 22 implemented, although I have to say that some of our 23 nurses do have concerns about whether that is actually 24 going to really happen. 25 If only the guidance that we do have -- and I do 0045 1 have some experience internationally, and I think we 2 probably have the best guidance in the world in relation 3 to the welfare of children and young people in 4 hospital -- if only that was implemented, then I feel 5 I could die happy, because one of the things that 6 I actually find very frustrating is that I actually 7 started children's nursing in 1959, the year of the 8 Platt report, and I am still fighting this week for 9 children to be in children's wards not adult wards, and 10 things not at the cutting edge like infant cardiac 11 surgery, but general surgery where children are in adult 12 wards because management is not prepared to implement 13 the guidance. 14 THE CHAIRMAN: May I interrupt, first of course to say 15 one hopes you will live a much longer life, but to ask, 16 what does "mandatory" mean to you, please? Maybe 17 Miss Grey was going to ask that, but I have asked it 18 first. 19 MISS BURR: That the recommendations would be required to 20 be implemented. Obviously there would need to be 21 a lead-in time and there would always be exceptional 22 circumstances, but there is a great deal that could be 23 done if people really thought they were required to 24 implement the guidance. 25 MISS GREY: Can I just pick up one thread of the earlier 0046 1 answer, it may be something that Liz would also like to 2 comment on. You mentioned there that one of the 3 problems, perhaps, in achieving implementation was that 4 there were not many nurses with children's nursing 5 experience in senior management positions so that is 6 allied, then, is it, to the point that is made at other 7 parts of the Royal College's statement that nurses have 8 had difficulty with children's qualifications in moving 9 up the career path into managerial roles? 10 MISS BURR: Yes, and in fact in managerial roles that is 11 becoming more difficult for children's nurses as the 12 number of posts in management roles for nurses has 13 reduced and whereas clinical opportunities have 14 increased in other areas, for example children's nurses 15 can become health visitors, community nurses, practice 16 nurses without having to undertake adult training; in 17 relation to management roles there are far less 18 paediatric management posts available now. 19 MRS JENKINS: Can I add some general comments about 20 management culture which may or may not have relevance 21 to the particular case we are looking at -- I really 22 would not know that. Having been both a Director of 23 Nursing and a General Manager, and in particular looking 24 back to the time period that we are talking about, many 25 Directors of Nursing in the mid-1980s would have found 0047 1 themselves as the only woman on the Management Board and 2 they would have found themselves with Directors of 3 Finance and Chief Executives who would have taken a very 4 strong line on the financial bottom line of their 5 organisation. 6 I think that one of the problems of management at 7 that time was for individual Directors of Nursing to 8 hold the line about the quality of care as opposed to 9 the financial implications of them. It was my 10 experience during that time that General Managers would 11 take short-term decisions which were financially cheaper 12 than looking at the long-term implications of, let us 13 say, in this case, if it was recruiting more paediatric 14 nurses. People did not think about risk assessment 15 then; they did not think that ten years down the line 16 there would be the sort of litigation and complaints 17 that there are now, and I think that in many areas in 18 the country it was very hard for Directors of Nursing to 19 have the voice and the ability to constantly stick with 20 what was best for their patients against what was 21 a culture of resource management. 22 Q. But to put it crudely, the Directors of Finance did have 23 the obligation of managing an organisation that remained 24 within budget, at a time when the national pot of money 25 was under severe constraints, or perceived to be under 0048 1 severe constraints, and the feeling was that clinicians 2 or nurses, perhaps, would always be demanding further 3 resources for higher and higher standards of care. 4 How do you go about reconciling those imperatives? 5 A. I think the answer to that -- I would entirely agree 6 with your statement; that is precisely how it felt for 7 me, as a Director of Nursing and also when I was the 8 General Manager. I think there has often been a failure 9 of General Managers to, if you like, abrogate their 10 responsibility to doctors and nurses who have the 11 clinical responsibilities, but at the same time, not 12 always providing them with the things that they want. 13 One of the other things I think is very 14 interesting, we did a survey of Chief Executives and 15 trust nurses about four years ago and we asked each 16 party -- we asked the Chief Executives what they valued 17 most from their Directors of Nursing and we asked the 18 Directors of Nursing what they thought their most valued 19 contribution was. It was quite fascinating. The 20 Directors of Nursing thought that on the whole their 21 major contribution was in strategic planning for the 22 organisation, and the Chief Executives valued most the 23 fact that their Directors of Nursing had a clinical 24 expertise that should allow them to be able to talk with 25 authority about patient care. 0049 1 So again there was a different perception in what 2 nurse managers often thought they were there for and 3 that again, I think, made it difficult for people to 4 resist those pressures of finance and to some extent to 5 go along with resource management rather than real 6 patient-focused care at the centre of each 7 organisation. 8 THE CHAIRMAN: May I press you on that question, because 9 I am not quite sure you really squared the circle of 10 Miss Grey's tension. It is one thing to say patient 11 care on the one hand and resource management on the 12 other, but they are the same thing from two different 13 sides? 14 A. I think what I am trying to say, Chair, is that 15 I think that it was particularly hard then, the culture 16 of quality which we have now was not as overt then and 17 I think that for Directors of Nursing to fight for what 18 they knew would be right for patient care against the 19 pressures of the bottom line was extremely hard. I am 20 not saying it was impossible, but it was hard. And 21 also, which I hope will square the circle, I think that 22 nurses in senior management positions then perceived 23 their job as being more financially orientated than 24 actually being there to ensure that the patient's voice, 25 whether that was a child or somebody with a mental 0050 1 illness, was heard at the Executive table. 2 Q. Forgive me if I press the point one more stage. To 3 fight is not the same as to prevail. There would be 4 good sense, perhaps, in making sure that your case was 5 heard; it does not follow from that that your case ought 6 to prevail if the Finance Director, for example, said 7 "There is not the money"? 8 A. I think that clearly you cannot do everything, and 9 a Director of Nursing, just as anybody else on a Trust 10 Board, has a responsibility to ensure that they provide 11 the best possible services within the existing financial 12 resources. 13 What I am saying is that I think that decisions 14 were often made that were short-term because perhaps the 15 nursing voice was either not heard or not spoken loud 16 enough for people to understand what the long-term 17 implications would be. 18 I certainly made some of those mistakes myself, as 19 a General Manager. 20 MISS GREY: Are there perhaps at least two strands in what 21 you are saying? Firstly that during the 1980s and early 22 1990s, many standards of care were implicit rather than 23 explicit, and a great deal of work has been done during 24 that period to bring those out into the open to provide 25 a benchmark against which nurse managers, say, can fight 0051 1 their corner in the battle to retain resources? Would 2 that be one element of your answer? 3 A. I think that would be fair, yes. 4 Q. And the second thing, perhaps, the conflict of roles: 5 that if the Nurse Manager or Director of Nursing 6 perceives her role as being one of planning resources 7 rather than advocating a particular view of patient 8 care, then there may be an absence of that voice at 9 Trust level, or planning or management level, within an 10 institution? 11 A. Either there may be that absence, or it may be 12 overridden. Let me just give you an example which 13 I think might be helpful, an example from my experience 14 as a Director of Nursing, when we had patients who had 15 to stay overnight in our A&E Department because there 16 were not enough hospital beds and this was happening 17 routinely. Everybody knew it was wrong, but because it 18 happened routinely, it became something that was simply 19 accepted. Fortunately, they were nursed on beds, but 20 they were not in the proper place where they should be 21 with the right facilities. 22 It was only when I took the Chief Executive down 23 to the A&E Department and made him see the patients and 24 actually showed him what the problem was that were we 25 able to re-open a ward, which was a very expensive thing 0052 1 to do. 2 I think so often what happens is that the 3 difficulties at ward level do not always reach the 4 executive table because the nurses do not necessarily 5 tell their Director of Nursing, for all sorts of 6 different reasons, or the nurse managers who may know 7 there is a problem, if there are some, may not feel that 8 they wish to take it to that top table. 9 So I think that if Chief Executives and the people 10 who make decisions actually saw and knew what was 11 happening, they at least are in a position to be able to 12 make a clear decision on what they are doing. 13 Q. Can I ask you, what would you see as the purpose or 14 function and importance of a Director of Nursing 15 throughout our period? 16 A. I have to say, it will depend on what their job was, 17 and there were all sorts of hybrid jobs. Some Directors 18 of Nursing had responsibility for the budget, for the 19 nursing and the accountability for that; others did 20 not. Many of them had quality as a sort of, I have to 21 say, added "lob on" because they seemed to think it was 22 a reasonable thing that nurses should take this. Some 23 had personnel functions added to their jobs. So there 24 were very many different jobs during that period of time 25 that were described as or incorporated the person who 0053 1 sat as the "nurse" on the Board. 2 My own personal view is that whether you had the 3 management of nursing and the finances for it in your 4 power or not, you were on that Board to provide the best 5 possible nursing advice for the benefit of patients to 6 that Board and that therefore, my own view is that you 7 would have a strong responsibility for ensuring that 8 patient care within your domain was as safe and as good 9 as it possibly could be, given the financial constraints 10 that you would have. 11 Q. I think it is implicit in your answer that you see it 12 as being important to have, at senior managerial level 13 or Trust Board level, if we are talking post-1991, 14 someone whose job description, as it were, encompasses 15 the role of speaking for the interests of nurses and 16 patients within the organisation? 17 A. I think it is the latter bit of that that I would 18 emphasise. I think that the nursing role on a Trust 19 Board has a responsibility for ensuring that the other 20 colleagues on that Trust Board understand the issues of 21 patient care and that they therefore ensure that they 22 are not making decisions that conflict with patient care 23 or safety. 24 Q. Why does that differ from the role of say a medical 25 officer or doctor who, if you asked him or her, would 0054 1 also say that his or her role was to advocate the 2 interests of patients and make sure their safety was not 3 compromised? 4 A. I am sure they would say that. The only answer I can 5 give is that nurses and nursing is a 24-hour service 6 throughout the year and the nurse on the Trust Board is 7 the only person who understands things like what it is 8 like in the middle of the night when you cannot get hold 9 of whatever facilities it is. They are the only people 10 who know how frustrating it is if there are not enough 11 porters to come and take the patients to theatre in an 12 emergency. 13 So I believe that the nurse on that Trust Board 14 has a unique role in advocating for the safety and 15 quality of patient care. 16 Q. So you would say that they were closer to the 17 "coalface", as it were, and in particular, they were 18 closer to the concerns or irritations, experiences, of 19 patients because possibly they were more accessible to 20 patients? 21 A. They might not be more accessible in the role that they 22 were in at that moment, but from their background, they 23 will have that experience, and it is one that I think 24 you, as a nurse, to some extent abrogate at your risk. 25 If you believe that the job you are doing is not about 0055 1 nursing and not about speaking up for nursing and 2 patient care, which is an easy thing to do but will mean 3 that the decision-making at that Trust will not be as 4 good as it should be. 5 Let me give you another example. There were 6 clear differences in management decisions in my view 7 from the era of general management to the era of a Trust 8 Board that did have a Medical Director and a Nurse 9 Director on it. Before then, I think that decisions 10 were even more business orientated in the first round of 11 general management, and less patient orientated. 12 Certainly, with clinical directorates and doctors 13 and nurses working together again to run swathes of the 14 organisation, we saw far better management decisions 15 which took into account the clinical care of clients. 16 Q. You have described the Director of Nursing as having, in 17 many institutions, many Trusts, perhaps, additional 18 add-on functions, whether they were personnel or 19 otherwise. Is there a danger in a situation in which 20 the Director of Nursing is also, perhaps, the Director 21 of Operations and as such functions as a deputy to the 22 Chief Executive, is there a point at which you may lose 23 a focus as a Director of Nursing? 24 A. I do not think necessarily by being Director of 25 Operations or Director of Quality, other than sometimes 0056 1 the jobs can be so big that they are extraordinarily 2 difficult to do, and I do not think the job of any 3 Director of Nursing on a Trust Board is an easy role to 4 fulfil. 5 No, I do not see any reason why a nurse should 6 not be a very effective Director of Operations, for all 7 the reasons I have said. In my view, nurses have 8 a unique understanding of how a hospital -- we are 9 talking about hospitals in this case, I am not 10 suggesting all Directors of Nursing run hospitals, but 11 I think they have a unique understanding of the range of 12 services. 13 Q. The reason I ask you is that we have heard commentary 14 from some witnesses at least that if the role of 15 Director of Nursing and Director of Operations were 16 combined, as it was at the BRI, there might at least be 17 a perception that nurses were not having their voice 18 heard at senior management level. 19 It may well be that that is a problem of 20 perception rather than reality, or that it depends on 21 the personnel involved. Is it a structural problem, or 22 is it a personnel problem? 23 A. I do not believe it is a structural problem. I believe 24 you could well be the Director of Nursing and Operations 25 and still be strongly advocating for nursing and patient 0057 1 care. Indeed, one might argue that the combination was 2 rather more logical than some of the others. 3 I think if the result is that there are problems, 4 then those will be about the individual people 5 fulfilling those roles. I do think that where nurses do 6 not have direct line accountability for nursing, they 7 have to work enormously hard to keep in touch with the 8 nursing workforce, for whom they no longer are the 9 direct line manager. That was the role I had. I had no 10 direct line responsibility for nursing, the provision of 11 nursing, or the budget. 12 To be in touch with what goes on requires walking 13 the job, knowing the names of your ward sisters, knowing 14 where the problems are. You can only do that by strong 15 networking with those teams of people, and them knowing 16 that they have your support in advocating for them. 17 Q. So is it a challenge to maintain what you might call 18 "clinical credibility" or "nursing credibility" once 19 you move into a managerial role and cease to have 20 front-line responsibility for patient services and 21 patients? 22 A. No, I do not think so, if you are the sort of person 23 who has the credibility of the nursing staff because of 24 your nursing influence. All nurses know, as I said 25 earlier on, that as they move up the managerial ladder, 0058 1 they will lose clinical credibility. It is some 2 probably 15 or 20 years since I resuscitated a patient 3 but I do not think that means that I do not have 4 credibility with nurses or would not have if I was back 5 in a Director role. I think what gives Nurse Managers 6 credibility is their leadership, their ability to 7 understand how the organisation works, their ability to 8 be accessible and to listen and their ability to support 9 their part of that organisation when it is required. 10 Q. Sue, I think I saw you nodding at that list of bullet 11 points? 12 MISS BURR: Yes, I totally agree with what Liz says. 13 MISS GREY: If I can turn back briefly to a small point 14 on the subject of guidelines, it is page 18 of the 15 statement, paragraph 5.9, where, after a recommendation 16 from the Department of Health on meeting various 17 standards, you say that Some health authorities 18 responded and obtained finances for general nurses to 19 train as RSCNs. Others did not. 20 "The RCN Paediatric Nurse Adviser is aware of some 21 managers who decided to amalgamate, on paper, their 22 children's wards and then claimed they did not meet the 23 Department of Health recommended minimum standards." 24 Reading that paragraph, it is not entirely clear 25 whether that is a criticism or praise of the 0059 1 institutions concerned? 2 MISS BURR: There is a mistake there, because that should 3 read, they claim that they did meet the Department of 4 Health recommended standards. 5 Q. So it was not a clever dodge in order to obtain 6 funding? 7 A. No, that was the difficulty that they did not obtain 8 funding, and I think that refers back, Miss Grey, to 9 what you asked me earlier and the difficulty of 10 implementing recommendations, because if the managers 11 did not have the insight into the need for this, their 12 response was, and this is following the Allitt Inquiry, 13 they did not catch on to the fact there was 14 an opportunity to get funding out of them. They saw it 15 as defending their unit. Therefore, their response back 16 to the department was, "We meet these recommendations". 17 One or two of them recognised that and were able 18 to get funding from the Department to support nurse 19 training, but the others decided on paper they would say 20 their three children's wards were now one, even though 21 that might be a 60-bedded unit and they had two RSCN on 22 at that time, then they met the recommendations. 23 I think that is very sad, and we had hoped that the 24 Clothier Inquiry would be more forceful in the 25 implementation of government guidance, other than, as it 0060 1 is said, it should be more closely observed. 2 Q. Again to clarify a point of detail, at paragraph 5.12 3 over the page, page 19, you set out the findings and 4 conclusions of the House of Commons Health Select 5 Committee on the question of benchmarking or monitoring 6 the admission of children into adult wards. 7 You then set out the government's response 8 at 5.13, where they took issue with the committee's 9 conclusions and findings. 10 Is it right to draw from that evidence the fact 11 that the government rejected that recommendation, or can 12 you update us on the situation? 13 A. I think the government response does not actually 14 respond appropriately to what the House of Commons 15 Select Committee said, because the House of Commons 16 Select Committee did not refer to those small number of 17 children who are in adult wards in totally adult 18 hospitals; they received considerable evidence from 19 a variety of people, including medical staff, that there 20 were children in units where there were children's wards 21 with empty beds but the children went into the adult 22 ward because that was what the surgeon wished them to 23 do, although it was not apparent that there was any good 24 clinical reason. It is something I often refer to as 25 the surgeon's "shoe-leather syndrome", they do not wish 0061 1 to walk down the corridor to the children's ward. 2 We still have a situation where "beds" tends to 3 equal "power" within a hospital, and people wish their 4 patients to be in what they consider to be "their" ward. 5 Q. I think we can see from the quotation set out that the 6 government's response did not actually address the issue 7 that was set out in the preceding paragraph. What 8 happened to the recommendation that data on this issue 9 be monitored? 10 A. We are not aware that anything has happened. Our 11 Paediatric Nurse Managers Forum undertook a survey last 12 year, which is at the printer's at the present time, 13 which showed that the third commonest reason for the 14 senior children's nurse in a district, it might be the 15 ward sister but might be a manager, her third commonest 16 reason for concern was children in an adult ward. Adult 17 nurses are very concerned about children being in adult 18 wards. 19 Q. One of the reasons that might lie behind a reluctance 20 to make guidance mandatory or to insist upon various 21 standards being met in this field would be a degree of 22 scepticism as to the degree of difference that nursing 23 by children's nurses actually makes to outcomes. 24 Throughout your evidence there are some references 25 to evidence as to the difference in outcome. If we look 0062 1 at page 226, for instance, this is the beginning, the 2 title page, of the Royal College of Nursing's evidence 3 to the Health Committee on Children's Health. 4 If we turn over the page, page 228, there are 5 some views set out as to the importance of the nursing 6 of children because of the physiological differences 7 between children and adults. 8 Can you help us as to the evidence that exists 9 upon the difference that children's nursing can make to 10 outcome? 11 A. There is very little what you might call hard scientific 12 evidence, and as Liz referred to earlier, we did not 13 actually have that in relation to Registered Nurses 14 until quite recently. 15 I am only aware of one specific study that has 16 been undertaken and that is not in the public domain. 17 Therefore, I think we have to take what I think 18 Professor Baum called "qualitative observation", because 19 I think now it would be very difficult to undertake 20 a proper, mega, randomised trial because of the ethical 21 considerations. 22 When I first became the adviser at the Royal 23 College of Nursing, I contacted the UKCC in relation to 24 what was the most common reason for nurses in instances 25 relating to children to come before the UKCC, and it was 0063 1 drugs, in those days, and it was very, very rarely 2 a children's nurse. That was incorporated, actually, 3 into their administration, their guidance on the 4 administration of drugs. 5 So to have hard evidence, we do not have hard 6 scientific evidence, but there is a great deal of 7 qualitative observation. Some of the people that gave 8 evidence to the Inquiry at the beginning, some of the 9 intensivists, of course had a situation where they had, 10 as Liz had, cared for, been responsible for children in 11 which adult nurses were caring for them, and then where 12 there are children's nurses, and I think it is 13 interesting that without fail they spoke of the 14 difference that children's nurses made to the care of 15 the children. 16 Q. You have mentioned a study which is not in the public 17 domain. Are you able to help us a little further on 18 what that study was and what its conclusions were? 19 A. My understanding is, and the Director of Nursing and 20 Family Services at the hospital concerned is happy to 21 discuss that with you, was that it did show that 22 children's nurses made a difference to outcome. 23 Q. Maybe we could perhaps follow that up later. I think 24 that perhaps the evidence that you were giving at the 25 outset of your evidence to the Inquiry today, Liz, in 0064 1 relation to the difference that children's nursing or 2 the knowledge that children's nursing made in the renal 3 unit in which you were working was possibly an example 4 of what Sue was just referring to; is that right? 5 A. I am quite sure it is right. I think again we just 6 need to be clear about that sort of difference. 7 Children have very different needs, psychologically, 8 physiologically and organically, and where they are 9 being looked after by children's nurses in a long-term 10 situation, there is not the slightest doubt that you can 11 see the differences. 12 You will never see the difference unless of 13 course a serious mistake is made when an adult nurse is 14 looking after a very sick child for a short period of 15 time. I do not doubt, and I do not think Sue would 16 doubt, that there have to be still in this country 17 occasions when children will have adult nurses attending 18 them. I think the amazing thing is that, as we have 19 seen from all this guidance, the person in charge of 20 that should have a paediatric qualification so that they 21 understand what they are doing in maybe allocating an 22 adult nurse and that with a child, particularly a very 23 young, very vulnerable child, then in my view it would 24 be that for any period of time, it would be very, very 25 foolish if you do not have a qualified RSCN who was also 0065 1 a specialist in the particular area. 2 So, for instance, I think an RSCN who was 3 a diabetic nurse specialist, one would not want to see 4 that nurse working in an intensive care unit without any 5 additional training and qualification. 6 Q. When you said a moment ago that you would not generally 7 see a difference in outcome or effect on a child who had 8 been nursed by an adult nurse -- barring the very 9 obvious and serious error -- for a short period of time, 10 what did you mean by a "short period of time"? 11 A. I think there are bound to be in this country at the 12 moment -- as Sue has said earlier, we still know that 13 there are many, many children being nursed in intensive 14 care units and on surgical wards by adult nurses. For 15 one shift, I think you would have to do an enormous 16 random trial to find any difference in the outcome of 17 that child, other than how the child itself might feel 18 about being looked after by somebody who does not have 19 a clue how to look after a child. 20 It is much like saying that many, many patients go 21 into hospitals and come out having had the right 22 operation, but they may have had an absolutely traumatic 23 experience in having that, because good outcomes are not 24 just about the right treatment; they are about the right 25 psychological and holistic impact that that treatment 0066 1 has. That is why it is my very strong belief that 2 wherever there are children being nursed, that there 3 must be paediatrically trained nurses in charge of that, 4 and nurses looking after them specifically. 5 MISS BURR: If I could just add that to that, I have 6 a slight difference with Liz because we do not know 7 whether even a short period of time is going to cause 8 damage to the child, particularly psychological damage, 9 and we may not know for many years later. 10 If I could give quite a recent example, at our own 11 paediatric nursing conference last year, a 14 year old 12 who has haemophilia spoke for us, and he gave a very 13 interesting description of how his very first experience 14 of hospital was when he attended his local A & E, not 15 for himself but for his younger brother who had fallen 16 over and he could not stop the bleeding. He felt the 17 way his brother was treated had put him off nursing. 18 He actually thought the nurses were real monsters. 19 When it was discovered that the brother had 20 haemophilia and he was to be tested, he was absolutely 21 petrified of being sent to what was the major children's 22 hospital in the area and he spoke of how he had 23 a totally different experience there with children's 24 nurses and he considered now the nurses as his mates 25 rather than monsters. That was not even him being 0067 1 treated in that A&E Department, it was his younger 2 brother. 3 Q. In looking at the experience of children's services in 4 a large Trust or hospital organisation pre-1991, how do 5 you think that children's hospitals have been able to 6 make their voice heard, because at an early part of your 7 statement you talk about the separate development of 8 children's hospitals as coming from a different 9 historical background to adult services, and it may be 10 that there is room for more than one point of view as to 11 whether or not children's hospitals have been able to 12 serve children well when they may have experienced 13 difficulties in fitting into the balance of services in 14 a big hospital organisation? 15 A. When the children's hospitals were very separate, then 16 obviously they had much more influence over what 17 happened. There are certain difficulties, when there 18 was development of districts in which there was a group 19 of hospitals of which one, and it was often numerically, 20 for example, here in Bristol, very small compared with 21 the whole of the maybe several hospitals, in relation to 22 speaking for children, if I could just give my own 23 experience: when I was in Birmingham as the senior tutor 24 for paediatric nursing, the Children's Hospital, which 25 is larger than Bristol, was one of the 10 hospitals in 0068 1 the district. I was not allowed to run paediatric study 2 days because they had to be district study days and 3 because the Children's Hospital was only one hospital, 4 there was not allowed to be children issues as part of 5 the district study days. 6 When the nursing process -- I do not know whether 7 you have heard of the nursing process, but it is to do 8 with patient care, the framework or sheets the nurses 9 filled in. The Children's Hospital was not allowed to 10 have separate ones; they had to be for the district; 11 only psychiatry and midwifery were allowed to have 12 something different. So it was very difficult sometimes 13 for the voice of the children to be heard. Sometimes, 14 within those units, too, as Liz referred to, it was 15 difficult, nurses felt overall for the nursing voice to 16 be heard. 17 Q. Does that mean that there is, therefore, a danger in 18 specialising services within a children's hospital 19 because it may be at the expense of losing influence 20 across hospital policy as a wider area? 21 A. The scenario we would wish to see now is that you had 22 a separate children's unit, but they must have the 23 back-up services, particularly of things like laboratory 24 and some of the other support services, that are 25 available if you have a much bigger scenario. 0069 1 Some of the North American situations, where you 2 have your Children's Hospital but it might be a separate 3 building but it is within the complex of other large 4 units, so you can share lots of things but the aspect of 5 the children's care is very definitely for children. 6 One of the difficulties we have seen was the 7 closure of some of the smaller children's hospitals 8 where they have moved into a much larger area, is that 9 you gradually see eroded, although they were promised 10 when they went there that things would remain very 11 different for children and there would be a voice for 12 the children, you see that eroded. So whereas they 13 might have had their own Accident & Emergency Department 14 and then when they moved in that was separate but 15 adjacent to the adult one but the nurses were 16 professionally responsible to the paediatric 17 directorate, you now see that being changed so they are 18 now responsible for the adult A&E directorate. There is 19 still a great need to be vigilant about the needs of the 20 children, that they are specifically identified, and if 21 you like, ringfenced. 22 MRS JENKINS: Could I just add one thing there? One of the 23 other things we have seen eroded which I am not quite 24 sure we have alluded to is the number of senior 25 paediatric nursing posts throughout the country, to the 0070 1 extent that Sue now frequently is rung up by Directors 2 of Nursing who are adult nurses but responsible for 3 children's services asking her how they should staff the 4 wards that they would have been able to staff and would 5 have known the answer, had they had a paediatric senior 6 nurse in post. 7 So the RCN is now having to give advice in 8 situations where we have actually fought against 9 something happening and now have to give them the advice 10 they need because they cannot get it from within their 11 own organisation. 12 Q. Can you just explain why those posts should have been 13 eroded? 14 A. I think Sue might be best to describe that. 15 MISS BURR: We have to think within the general situation. 16 A lot of Nurse Manager posts have been removed across the 17 whole of the NHS, so there is that scenario. 18 Q. Could you just date that? Do you mean over the last 19 decade, since 1994, in the last few years? 20 MRS JENKINS: Probably since the inception of general 21 management, I would think from about 1983/84. 22 MISS BURR: There is that general scenario. Then we 23 have the situation that often the children's unit 24 numerically, a lot goes on numbers and beds, they are 25 quite small. So it is for example at the moment very 0071 1 common to amalgamate the children's unit with what is 2 called "maternal and child health". But traditionally, 3 obstetricians and midwives would appear to be more 4 assertive, powerful may be another word, than perhaps on 5 the children's side, so that it is very common that the 6 senior post on nursing midwifery would go to a midwife. 7 In fact, some of our large tertiary hospitals are 8 heading very much towards that situation, where they do 9 not have a children's nurse as the senior nurse over 10 their directorate. 11 Q. If I may, I would like to move to a different topic, 12 which is of that audit and the introduction of both 13 nursing and clinical audit throughout our period. 14 If we could go just by way of an introduction to 15 page 444, you will see there the title page of a review 16 of the use of the dynamic standard setting system in the 17 NHS of the 1990s, which I think is referred to as 18 DySSSy; is that right? 19 A. That is right. 20 Q. This is a system which was led or introduced by the 21 RCA as being an appropriate method for nurses or 22 multi-professional groups to carry out audit from the 23 beginning of 1990 or thereabouts onwards? 24 A. That is correct. 25 Q. Can you tell us a little as to the variety of practises 0072 1 that, if we are looking in the late 1980s, the beginning 2 of 1990, you would have found if you had looked across 3 the NHS at that time, being used by nurses to undertake 4 some form of audit activity? 5 MRS JENKINS: I think that you would have found, in most 6 hospitals or community trusts, somewhere, that there 7 would have been a group of nurses working with 8 colleagues trying to set standards to improve their 9 patients' care. They may not necessarily have been 10 using DySSSy. There were other methods, and it was, if 11 you like, at the beginning of the sort of drive where, 12 again, as so often happens in North America, we began to 13 see systems of standard setting. 14 So I think that there will have been a wide 15 variety, but it will have been very patchy, and even in 16 one organisation where you might have had a ward or 17 a department who might have set several standards and 18 been routinely working through them and auditing them, 19 you would equally have found parts of that organisation 20 that had never heard of them, would not have known how 21 to go about it and would not have thought it was 22 necessary for them to do. 23 So very patchy, but some very good work being 24 done. 25 Q. How did that position alter, then, if we turn to the 0073 1 period from 1990 to 1995? 2 A. I think it has altered simply because progressive -- 3 I was going to say progressive governments, but we have 4 not had that many, have we? The change of government 5 undoubtedly brought to the NHS a far greater push for 6 quality. That does not mean that the last government 7 did not expect there to be a high quality for the NHS, 8 but for the first time it was made absolutely explicit 9 and of course with clinical governance, now of course it 10 is quite explicit that it is the responsibility of the 11 Chief Executive that quality is audited and all the 12 other things that come into clinical governance. 13 Q. That refers to the change in government in 1997. If we 14 push back, if one looks at medical audit, you can trace 15 the formal requirement that that should be carried out 16 by practitioners to 1989. How does that compare to the 17 situation for nurses? 18 A. As far as I am aware, there was no formal requirement. 19 As I said earlier in giving evidence, it is my belief 20 that nurses have been, in different parts of the 21 country, working on improving quality standards for the 22 last two, three -- well, longer than that, decades. It 23 is what Florence Nightingale started to do in 24 a systematic way, but there was no actual requirement, 25 other than those parts of nursing that fell within 0074 1 things like some of the Conservative government 2 standards for things like outpatient appointments that 3 nurses may have had some impact on, but there was no 4 mandatory need for nurses to change their standards. 5 Q. Did the renaming of medical audit as clinical audit and 6 the change in emphasis that that was meant to imply from 7 single professional audit to multi-professional audit, 8 make any difference to the situation you have just 9 described? 10 A. I think that is very difficult to answer. I think that 11 it did, in those areas where the doctors and the nurses 12 had historically worked as a multidisciplinary team 13 anyway, but you might argue that if they had been 14 working in a multidisciplinary way, they would have been 15 doing clinical audit, whether they called it that or 16 not. 17 I think that there are still areas where it is 18 difficult for nurses to convince medical colleagues that 19 the sorts of things they wished to change and improve 20 have as much legitimacy as those things that the doctors 21 wish to improve, and undoubtedly, there has been 22 infinitely more money poured in the direction of medical 23 audit, whether it is medical audit or clinical audit, 24 than the sort of stuff which is often seen as "softer", 25 which is nursing. 0075 1 Q. If we go back to DySSSy, we can look at the philosophy 2 of the system at page 461 of this document, where the 3 elements of the system are set out. If we just scroll 4 down a little bit, you see there obviously terminology 5 and steps that you are very familiar with, in 6 particular, an initial describing phase where 7 a facilitator helps to set a topic for improvement and 8 to devise a statement of the intentions of the 9 programme. Then a secondary stage, once criteria have 10 been identified, where one starts to measure practice 11 against the standard, and then, finally, the final phase 12 of the cycle involving action planning. 13 To what extent did this method of audit, appraisal 14 of practice, succeed in becoming established in nursing 15 practice or multi-professional clinical practice, from 16 about 1990 to 1995, when the study was conducted? 17 MRS JENKINS: I think it had considerable impact, and 18 although I say it may have been sporadic around the 19 country, this system, as described here, which 20 undoubtedly will have come from probably the North 21 American model in the first place, is actually very much 22 the framework on which clinical governance has now been 23 established. I do not think there is much doubt that 24 DySSSy has played a very large part in some of the 25 requirements that are now set. 0076 1 So I believe that it is probably one of the most 2 powerful tools nurses had, and I do believe that they 3 used it. 4 The interesting thing that I found was, because to 5 some extent I was not in the RCN, I was not working for 6 the RCN when this was produced, but nurses in my 7 hospital were DySSSy-ing away and writing standards, but 8 would be totally unsatisfied if they could not audit 9 them; they did not believe that there was any point in 10 setting standards unless you could complete the cycle. 11 That, I think, demonstrates how hard nurses take 12 the quality of care for their patients, because they 13 recognise that it is a waste of time to write a standard 14 that you cannot measure and that you cannot audit and 15 that you cannot continue to improve. 16 Q. But what were the obstacles for them to continue by 17 auditing the standards they had been setting? 18 A. The obstacles, I think, were often the very pragmatic 19 obstacles of getting the right people together to take 20 this seriously. I remember a standard that was being 21 set which was something which you would think was so 22 straightforward, which was about the dignity of the 23 patient from the operating theatre back to the ward. 24 Nurses were distressed in my hospital that patients were 25 often taken out of the operating theatre fairly scantily 0077 1 clad and without adequate protection on the trolley that 2 was taking them, and it took them 18 months to even get 3 the standard to a level where they felt that it was the 4 right standard, because they had to work with porters 5 and technicians and lift engineers and the linen 6 department. There were so many facets that were built 7 into that one standard. 8 That made standard setting very slow. It took 9 a long time for each standard to be properly researched 10 and worked through. 11 And the opposite part to what were the barriers: 12 you might argue what made the nurses go on doing it? 13 What was the incentive for them to bother to do this 14 when no-one was actually asking them? The answer to 15 that is that nurses care about what happens to their 16 patients and the one thing that frustrates nurses most 17 is when they feel that they have not been able to 18 deliver the standard of care that they think is 19 adequate. 20 Q. The Royal Colleges on the medical front were from 21 1989 onwards coupled with the government requirement to 22 participate in medical audit, imposing on their members 23 a duty to participate in audit. Was there any similar 24 guidance emanating from the UKCC or the RCN to encourage 25 or to require nurses to become involved in audit? Or 0078 1 was it a matter of professional enthusiasm at a local 2 level? 3 A. There was encouragement from the RCN. As far as I am 4 aware, there was no mandatory requirement. I have to be 5 vaguely cynical, though, about how successful medical 6 audit was, despite there being a mandatory requirement. 7 That meant, certainly in my hospital at the time, 8 consultants having an afternoon off to discuss medical 9 audit once a month, and not a lot of outcome appearing 10 to happen, and also, in those early days, real 11 difficulty in making that multidisciplinary. 12 I can think of examples, not necessarily from my 13 own organisation, but where meetings that I went to, you 14 know, across the country, where doctors would not even 15 want medical students to take part in the clinical audit 16 meetings in case the medical students actually really 17 found out what the results were. I mean, there was real 18 fear and anxiety about it, and I have to say, a lot of 19 lip-service paid to it. 20 Nowadays there is a much more open culture to look 21 at what is done -- perhaps still not enough, I do not 22 think that results are published enough, that 23 demonstrate the difference between one clinician or 24 another, one firm and another, or even one hospital and 25 another. 0079 1 Q. If we look at the chapter in this study on 2 multi-professional clinical audit, which starts at page 3 507, it may be that it picks up much of what you have 4 just been saying. 5 If we look at the second paragraph [WIT 42/508], 6 we see the DySSSy model was conceived as being one which 7 had the potential to be used with multi-professional 8 groups, and that from the outset nurses were encouraged 9 to involve members of other disciplines appropriate and 10 in many places the move to clinical audit had been 11 a natural progression from multidisciplinary standard 12 setting and audit. 13 Does that accord with your experience and is 14 there a contrast there between the philosophy of this 15 approach and of that medical audit? 16 A. I would agree with the first part of that, I think, that 17 what we are saying, yes, it was for those nurses who had 18 been for a long time trying to improve their practice, 19 it was a natural progression. I think it would be not 20 correct for me to be able to comment in detail about 21 medical audit, because I was only ever involved at the 22 edges, mainly because I was never allowed in to get 23 involved with it. 24 Q. If we go on then in this study, we have moved down 25 a little bit to comments on professional tribalism and 0080 1 the study makes the point that there have been 2 resentments or misunderstandings between different 3 professions and in the case of audit -- I am looking at 4 the second paragraph, the second column -- many of the 5 problems resolved around issues of methodology coming 6 out of the historical development of different 7 professions to audit. 8 It goes on to highlight different professional 9 interpretations of audit. 10 If we go over the page, we see nurses were 11 complaining about the secrecy of medical audit in 12 describing their anger at being asked to leave clinical 13 audit meetings for the medical audit part, even if they 14 had been willing to share the results of nursing audit. 15 There is there a contrast between approaches between the 16 two professions. 17 It may be that I am taking you on to areas you do 18 not have direct experience of, but where you are 19 familiar with the area, does that accord with your 20 experience? 21 MRS JENKINS: Absolutely. That is what I was trying to 22 describe a few minutes ago. 23 Q. Then, at page 511 of the study, there is a comment there 24 on the need for effective communication between groups, 25 and the difficulties in achieving an exchange of 0081 1 information between different professional groups and 2 various comments, feedbacks on the difficulties in 3 achieving that. 4 If we go down to the bottom of the page, there is 5 a comment that most Trusts were implementing 6 a directorate structure of management and that as these 7 individual directorates became increasingly autonomous, 8 more communication problems arose. 9 Then there is an example of in one organisation, 10 directorate, of clinical audit facilitators being 11 accountable to General Managers, whereas other people 12 were accountable to other individuals. 13 Can you help us, do you think that the 14 introduction of clinical directorates did on occasion 15 lead to problems of fragmentation or communication? 16 A. I was a great advocate of the Clinical Directorate 17 system and in fact was able to be part of setting it up 18 when I went to Guy's Hospital. One of the reasons I was 19 so keen on it was that we had actually worked in that 20 system in the Guy's renal unit, but that was rather 21 different in that that was a specialist unit which was, 22 if you like, rather different from the rest of the 23 hospital anyway, so we were quite autonomous. 24 I found that when we set up clinical directorates 25 first, there was better decision-making because it was 0082 1 being taken at local level about local issues. That was 2 good and still happens today -- 3 Q. If I might interrupt you, am I right in thinking that 4 that would have been the strongest reason for 5 introducing the Clinical Director system in the first 6 place, the desire to devolve down to a local level was 7 one of the driving forces behind their creation? 8 A. I think the driving force was the difficulty that top 9 management had had previously in containing clinical 10 expenditure where doctors, particularly, feel very 11 strongly that their clinical autonomy and authority 12 cannot be questioned, and therefore it was hard to 13 control budgets at the Board level when the people who 14 spent the money were the clinicians. 15 The move toward clinical directorates, as 16 I understand it, was to do two things: to take 17 decision-making to the lowest possible clinical level, 18 but also, to invest in those people at that level the 19 authority for the spend, because they were the people 20 who were making the spend, so they held the budget. 21 It is very easy, as I am sure you can understand, 22 to spend somebody else's money when you do not have to 23 account for it. 24 Q. I interrupted you, though, because you were telling me 25 of your experience in the introduction? 0083 1 A. I think as clinical directorates were set up, there was 2 better decision-making initially, and I think it worked 3 for a while. I think there is a difficulty of 4 fragmentation across directorates. The example I would 5 use in my experience was that it was about nurse 6 recruitment. In a Clinical Directorate structure now, 7 nurses will apply for a job in a directorate and if they 8 do not get it, for whatever reason, but let us say 9 because actually there is no post there for them to get, 10 they fall out of the system. 11 If they then want to apply to the same hospital, 12 they have to apply to another directorate. The system 13 of having a Personnel Department that works across the 14 whole organisation, so that if a nurse applies for a job 15 in elderly care but there is not one available, somebody 16 says, "Why do you not work on our medical ward for six 17 months until a job comes up?", does not seem to exist. 18 So I think that the strength of clinical 19 directorates, that one had lost some of that corporate 20 cross-organisational strategy and the only people that 21 held that together are the Trust Board. They therefore 22 get fed information up several different strands, which 23 I think can make the corporacy of their decision-making 24 harder, which is why, earlier, I advocate for Nurse 25 Directors and others to have responsibilities that go 0084 1 across hospitals at all levels. In other words, it is 2 my belief that some sort of matrix system is probably 3 the best and a Clinical Directorate system can 4 undoubtedly lead to fierce defence of your own budget 5 and your own spend and not a lot of corporate 6 decision-making. 7 MISS BURR: If I could just add to Liz, from the point of 8 view of the children, the difficulty that sometimes it 9 is not that all children are within a children's 10 Clinical Directorate, so surgical children may be in 11 a surgical directorate which is adult focused or may be 12 within a cardiac directorate that is mostly adult 13 focused and the children's directorate becomes small 14 because it only includes paediatrics, medical and they 15 are subsumed into an adult directorate. So there are 16 particular difficulties for getting the voice of the 17 child heard if there is not a children's directorate 18 that includes all children. 19 Q. Thank you. Turning back to the conclusions of the study 20 on the implementation of audit in 1995, we find an 21 executive summary at page 451 of the findings. The 22 first part sets out the methodology of the study. If we 23 come down to the bottom two paragraphs, we see that 24 improvements in patient care were described in all the 25 sites visited with DySSSy appearing to act as 0085 1 a catalyst. Would that again accord with your 2 experience? 3 A. Yes, it would. 4 Q. We also see there were problems on committing time 5 to local quality improvement projects and that continues 6 to raise a difficulty. We will see that further over 7 the page. It also goes on to say the involvement of 8 patients in DySSSy varied with all standards described 9 as being "patient centred", although patients were 10 rarely involved. 11 I see some nods coming from the two of you at this 12 point. 13 MRS JENKINS: I will speak for adult patients and let Sue 14 speak for the children. 15 I think that there were areas where, particularly 16 in areas of chronic care like renal disease or some of 17 the diabetes, where patients did get involved, because 18 in fact patients are often the best judges of their own 19 clinical care. I do not think that is anything like as 20 easy to do in general surgery, general medicine and the 21 less specific areas. 22 MISS BURR: In children's nursing we have worked more 23 closely with the parent groups and in relation to things 24 like standards, the organisation Action for Sick 25 Children has produced a lot of documents where we have 0086 1 worked with them and they have worked with us in some of 2 our documents as well. It is often in our situation the 3 parent rather than the child. 4 But there are some very good developments more 5 recently where some of the children's hospitals have 6 Quality Circles in which they have involved children and 7 ourselves, our own -- which will be national 8 multidisciplinary guidelines in relation to children's 9 pain, we had a children's conference in which the 10 children were facilitated to assist in the development 11 of those. They will be presenting them, and there is 12 also separate information for children, so that is 13 increasing, but certainly if we go back to 1984, it 14 would have been far more unusual. 15 Q. If we turn over the page, page 452, we see firstly the 16 conclusion that the personality skills and attributes of 17 the key facilitator were highly important and that you 18 needed trained and supported personnel in order to be 19 able to introduce a system like that. 20 That point is picked on and developed in the 21 following paragraph, where they comment on the lack of 22 training and education, principally for systems for 23 quality improvement and skills in group work and 24 facilitation, being raised as a barrier to further 25 development in many areas. 0087 1 Perhaps if I may, could I take you here back to 2 your statement where, at paragraph 12.4, which is at 3 page 27 of your witness statement, WIT 42/27, you talk 4 about the lack of learning systems in organisations and 5 comment upon that in the context of the NHS. 6 Can I ask you to expand a little bit about the 7 extent to which NHS structures, organisations, have 8 succeeded in being able to facilitate and encourage 9 learning and staff development? 10 MRS JENKINS: I think it is a mixed bag. The Trusts, 11 the hospitals that have as their leaders those people 12 who genuinely understand what patient care is about and 13 what motivates the staff who have front-line decision 14 for patients use the experience of things like the 15 magnet hospital that I spoke about before: they 16 undertake staff development and review, they invest in 17 training and professional development for their staff, 18 not just medical staff where it may be mandatory, but 19 for all staff. 20 Equally, there are Trusts and health care 21 organisations where that is very spasmodic. Of the 22 conferences that we run for nurses, I would say, for 23 most of those conferences, at least 75 per cent of the 24 participants will not have been fully funded to attend 25 and will not have been given time off to attend. They 0088 1 will have paid for some of it themselves and will have 2 taken some of it in their own time. 3 I am not saying that is a criticism, I am saying 4 that the budgets for training and development for 5 nursing, let alone others, is still relatively small, 6 and I think it is only the most progressive Trust Boards 7 that take it very seriously. 8 MISS BURR: If I could just add in relation to children, 9 particularly if there is one children's ward in 10 a district general hospital, and of course most of our 11 children are nursed in district general hospitals, there 12 is a system where each ward is allowed money for one 13 conference a year. If you are the only paediatric ward, 14 that means it is very difficult for the staff to keep 15 updated on what is going on in general paediatrics 16 because you are treated (and I understand why) the same 17 as other wards although there might be six general 18 surgical adult wards and the children's ward might cover 19 the whole of medicine and surgery from 0 to 16. 20 So it is particularly difficult for children's 21 nurses. 22 Yesterday, at our Paediatric Intensive Care Nurses 23 forum, on which there should be seven steering group 24 members elected from the country, only five could 25 attend; the other two, the ITU situation was such that 0089 1 they could not be relieved. Of the five that were 2 there, three came in on their day off because of 3 staffing situations. 4 Q. Is there a difference here, or is there likely to be 5 one, between the district general hospital and the large 6 teaching hospital? 7 A. In generalisation in relation to children, if the 8 children's needs are accepted, then I do not think it 9 depends specifically. It depends on the leadership and 10 the will of the people who make the decisions. 11 Obviously, of course, the financial situation as well. 12 Perhaps a very good example is something called 13 "paediatric benchmarking", which tends to be referred 14 to as the "north-western region" because that is where 15 it started, where an individual nurse has been able to 16 expand a situation. She works between a university and 17 quite a big children's unit within a district general 18 hospital. She has been able to encourage nurses, often 19 in their own times, from something like 26 Trusts and 20 universities involved now, to benchmark basic standards 21 of children's care across the situation from different 22 units, and she received quite considerable opposition to 23 start with, and so did some of the individual nurses 24 because we were in a situation of competition and they 25 felt that the information was confidential to their 0090 1 Trust. 2 I think that has been a very good example of how 3 small children's units if they are in a network can have 4 peer support, but they can use the standards to improve 5 practice. For example, what they found by meeting 6 together was some anaesthetists who anaesthetised in one 7 hospital were quite happy to have parents in the 8 anaesthetic room because that had been the arrangement 9 for some time, but when they visited another hospital, 10 they would not allow parents in the anaesthetic room. 11 Of course the nurses did not know that when they were 12 separate; when they were able to get together and 13 benchmark that standard, they were able to go to the 14 individuals concerned and say "How is it you are happy 15 to have parents in one situation [and of course that is 16 the Department of Health guidance], but not on in 17 another situation?" Most of them then gave in and were 18 happy to have parents present. 19 I think that is an example of how it can be done 20 if you have leadership and the facility for the nurses 21 to network. 22 MRS JENKINS: Just a quick general comment on the 23 differences between district general hospitals and the 24 teaching hospitals. I think you will usually find in 25 teaching hospitals the culture of teaching and 0091 1 development may be slightly higher, but you would also 2 find, because teaching hospitals are called teaching 3 hospitals because they are medical teaching hospitals, 4 that a vast amount of the money will be towards medical 5 teaching, and even those big hospitals that have special 6 trustees' funding that are available to them, if you 7 look at how those are spent, 99 per cent of them will be 8 spent on medical research or medical innovation and not 9 on nursing. 10 Q. If we stick with this passage from the RCN statement 11 here and look at paragraph 12.2, you comment there that 12 changes in managerial structures in the last decade may 13 have had the unintended consequence of weakening the 14 system for the identification and monitoring and 15 investigation of untoward incidents and that clinicians, 16 both doctors and nurses, may be inclined to keep matters 17 in their own hands and to resent inquiries by managers. 18 Then you talk about the perceptions of managerial 19 indifference, clinical freedom, unwillingness to admit 20 problems, or even the reluctance to face the death of 21 a patient. 22 Can I ask you to hold that paragraph in your mind 23 and if we could go back to the findings of the DySSSy 24 study, at page 452 we see in the third paragraph of that 25 report some of those interviewed felt that the biggest 0092 1 benefit of the purchaser/provider split was that quality 2 issues had been introduced in areas where they had not 3 previously featured and that applications for Trust 4 status had helped some organisations draw existing 5 initiatives together into a coherent, one might add, 6 quality strategy. 7 There is something of a contrast between those two 8 paragraphs on the judgment that is being made on the 9 introduction of the NHS reforms from 1991 onwards. 10 Can I ask you to comment on the balance between 11 the two? 12 MRS JENKINS: I think I can only comment in much the 13 same way as I have answered several of your questions, 14 in that I think that the way the NHS is run in different 15 Trusts and parts of the country vary enormously; and 16 that in some Trusts people have taken government reforms 17 and worked with them to get the very best that they can 18 for their patients and clients. In others, they have 19 not. 20 So although I accept that the two statements may 21 be from a slightly different perspective, remember, one 22 has been written by a group of people who are passionate 23 about quality improvement, and who I think are looking 24 for the good examples, whereas the other that is in our 25 introduction may be a slightly more universal and 0093 1 possibly slightly more cynical view that there are 2 still, and we know that there are still, areas where 3 people do find it very difficult to accept that mistakes 4 are made or that systems are not as perfect as they 5 would like. You only have to look at the NHS complaints 6 systems and the problems that have arisen out of that to 7 see that many, many NHS staff do not like admitting that 8 something has gone wrong. 9 Q. But if I can press you a little further, if we go back 10 to 12.2, page 27, what is being suggested there is that 11 there is a link between changes in management structure 12 and increasing reluctance or weakening of complaints 13 systems or willingness to admit fault, not merely that 14 individuals have taken the same reforms in different 15 directions? 16 A. Yes, and I think that links in with what I was saying 17 about the sort of Clinical Directorate system. When 18 I was a Nursing Officer in charge of the Guy's renal 19 unit in, let us say, 1982, I would have had a Senior 20 Nursing Officer, a Divisional Nursing Officer and 21 a District Nursing Officer on the same site and 22 a Regional Nursing Officer somewhere at a distance. If 23 I needed anything doing in my renal unit I had to go all 24 the way up that chain because it was only the Regional 25 allocation to my unit that would make a difference. 0094 1 Then of course the message would come all the way down 2 again, which seemed to take a very long time, but at 3 least the people I was talking to were people who were 4 nurses who one hoped felt as passionately about the 5 business I was in as the one they were in. 6 What I think this is suggesting in paragraph 12.2 7 is that the managerial structures are much more likely, 8 the ward sister is probably accountable to somebody who 9 is not a nurse who has probably only worked in 10 a hospital for maybe a few years, and who therefore, if 11 you like, does not have the same understanding of the 12 clinical issues, and therefore may weaken the system of 13 monitoring things that go wrong. 14 I do not think this paragraph is trying to say 15 that everything in the old days was better, because it 16 undoubtedly was not, but that the changes have both in 17 some ways strengthened some areas but may have weakened 18 others. 19 Q. Can you just summarise briefly the areas you think have 20 been strengthened as opposed to those you think have 21 been weakened? 22 A. I think that the directorate structure has injected into 23 big organisations -- and let us face it, many of our 24 Trusts are now enormous because there have been so many 25 mergers. A directorate structure does allow a group of 0095 1 staff to feel that they belong to a particular team and 2 that they have a particular head, a Clinical Director or 3 whatever, and if the leadership within that directorate 4 works well, then I think it is a motivator to staff. 5 If you work in a Trust that employs 5,000 or 6,000 6 people, it is hard to believe, you know, that you belong 7 anywhere. So I think that there has been some sense 8 where there is good teamwork and good leadership, the 9 directorate structure has made owning problems a good 10 thing, whereas again, what I think is missing is the -- 11 we are talking about a vertical directorate structure -- 12 what seems to be missing, often, is the horizontal 13 structures that hold the thing together often in the 14 middle, and therefore, there is a lack of corporacy, and 15 the ability, if it should happen, for people to "pass 16 the buck", for people to fudge the issues, for things 17 not to be so visible to those who are the managers. 18 It is very hard, if you are on the Trust Board, to 19 know everything that happens in your organisation. 20 Q. If I move on to the next paragraph, 12.3, you talk there 21 about the organisational culture and its importance. 22 You conclude in the last paragraph that the RCN has long 23 argued for independent counselling to be provided for 24 NHS staff. 25 Is there a contrast to be drawn between the 0096 1 emphasis to be placed upon staff counselling, support, 2 occupational health, within the NHS and that given by 3 other similarly large organisations or businesses? 4 A. I am sorry, I am not sure I understand your question. 5 Q. I think the question I was asking was that you say 6 there you have been arguing for independent counselling, 7 and behind that point lies another point about the 8 extent to which that is made available now. 9 What I am asking for is a comparison, if there 10 is one to be drawn, between the emphasis the NHS has put 11 upon staff, support, counselling, occupational health 12 and that which has been given by other organisations of 13 similarly large size? 14 A. I am not sure I can comment on other organisations. 15 I am not sure what counselling they provide. There is 16 more counselling for front-of-house staff now than there 17 used to be. I do not think there is, my guess would be, 18 as much as similar organisations whose work is as 19 stressful and as emotionally draining as nursing. And 20 I think that this is just simply saying that we have 21 said for a long time that given the structures within 22 which nurses work now, there is a need for more support 23 and openness. 24 The only thing I would just want to add to that, 25 because that rather, reading it the way it is written, 0097 1 almost implies that counselling is the answer to the 2 problem, and I do not believe that counselling is the 3 answer to the problem tomorrow. Counselling is required 4 to some extent because of some of the problems. 5 I would just like to refer to some work that was 6 done after the Clothier Inquiry, as a result of the 7 Allitt case, when the RCN was looking at how we could 8 ensure that these things did not happen again. I just 9 want to bring them together, because they touch on many 10 of the things we have talked about this morning, but we 11 drew up some guidance for managers to ensure that people 12 were able to bring to the attention of those in charge 13 the issues that they had and the list that we came up 14 with was about protocol development, standard setting 15 and audit mechanisms, good communication systems, which 16 is one of the things that I am saying I think may get 17 missed in a directorate structure, a robust complaints 18 process, multidisciplinary team review, so that you were 19 not just looking at what nurses did or what doctors did, 20 but you were actually looking at what the team did. 21 Obviously sound education, very robust selection 22 procedures, staff development and review, sickness and 23 absence policy and clinical supervision. 24 What we were saying was that if, as a manager, you 25 felt confident that you provided that within your 0098 1 organisation, then you would have a culture where people 2 were able to raise their concerns without there being 3 managerial indifference or unwillingness to admit 4 problems or reluctance to face things like that. 5 Q. Can you just give us the date for that work? 6 A. 1995. 7 Q. Presumably the thing that lay behind it was the 8 enormous amount of work that would be needed to 9 translate the existing culture into the culture that you 10 were describing? 11 A. An enormous amount of work in those Trusts and parts of 12 the organisation where these things are not considered 13 to be the normal part of good management, but I would 14 have to say that none of those things surprised me, or 15 made me think, "Oh my God, we should have thought about 16 this ten years ago". All of these things have existed 17 in different forms in the NHS for years. What had not 18 happened is that people had not packaged them together, 19 and it was very interesting, because of course that list 20 is not a million miles from the list of attributes of 21 a magnet hospital, which I described, and I think that 22 in the best directorates, units, where nurses are happy 23 working and where patients are well looked after, you 24 would find that most of those exist already. 25 Q. I think that in effect takes us on to paragraph 12.6 of 0099 1 this part of the statement, where, looking at the rapid 2 change in the NHS at the time, there is comment there 3 on, in particular, the concern that with hospitals and 4 units competing against each other to provide health 5 services, there might be or there was an introduction of 6 clauses in contracts of employment which prevented the 7 sharing of developments in practice, and also 8 confidentiality clauses that prevented staff from 9 speaking out. 10 What was the experience of the RCN in this 11 field, from 1991 onwards? 12 A. That more and more of those confidentiality clauses 13 were noticed, coming in, and certainly, there was -- 14 I do not know, because I am not working in the NHS now, 15 whether it still exists, but there was a period of time 16 when Trusts were first being set up where it was quite 17 ridiculous, in that it was almost impossible to get 18 information about what was going on in the hospital down 19 the road. Guys and Thomas's, before they merged, 20 I could not find out anything about what was going on in 21 a hospital which was less than three miles away. 22 Q. Was that to do with clauses and contracts, or just the 23 general atmosphere of the time? 24 A. I think the general atmosphere of the time meant we 25 were fighting for the same group of patients so we did 0100 1 not want to give them information about what we were 2 doing and they clearly did not want to give us 3 information either. 4 I think that has changed. I think that was the 5 early days of what was genuinely seen as Margaret 6 Thatcher's competitive type of National Health Service 7 and I do not think it lasted very long. I do think the 8 issue of the confidentiality clauses which were part of 9 individuals' contracts became quite fashionable, 10 probably around the early 1990s, late 1980s/early 1990s 11 and we worked very hard to get those removed. 12 Q. Was this an area where there was a great deal of fear 13 that these would be introduced but in fact very little 14 success, or even attempts to introduce them? 15 A. They were introduced in quite a few places. 16 Q. There may have been an atmosphere of concerns that did 17 not in fact materialise, or the concerns might have been 18 justified? 19 A. I think the reason that they existed is because nurses 20 did start speaking out about things -- not just nurses 21 but there was a particular nurse who became quite well 22 known who had spoken out, and it became of national 23 interest, and organisations were worried, Trust Boards 24 were worried, that that sort of thing would happen. 25 Our view had always been that if you ran an 0101 1 organisation with the right sort of culture of trust and 2 openness, then you did not need to worry about any sort 3 of gagging clause or confidentiality clause. It is 4 always irritating when you are on a Trust Board and you 5 open the newspaper the following day and find that one 6 of your nurses has said something about your 7 organisation that you did not expect them to say, and 8 I think it is perfectly reasonable for managers to 9 expect staff to air their problems not for the first 10 time in the press. But that can only happen if you have 11 a culture where people are able to share their concerns 12 about colleagues with confidence, and without any fear 13 of recrimination for themselves or their colleague. 14 Can I give you an example of that? If I am 15 a nurse working on a ward and I notice that the junior 16 doctor is beginning to behave rather oddly and I think 17 that his performance is not as good as it was, I may 18 want to go and take that to somebody and tell them that 19 I am concerned about him. I do not mean by that I think 20 he should be suspended and some sort of disciplinary 21 procedure should be started. He may be sick, he may 22 have major problems in his out-of-work life. There are 23 many things that can make people's performance change 24 and they need protection and looking after as much as 25 the person -- 0102 1 MEMBER OF THE PUBLIC: What about the victim? That is not 2 what happens in hospital, is it? This hospital in 3 Bristol killed my wife, and I had help in nobody. 4 No-one at all. 5 THE CHAIRMAN: Could you possibly give me your name? 6 MR GERRISH: My name is Trevor Gerrish. 7 THE CHAIRMAN: Mr Gerrish, thank you for your intervention. 8 As you know, we have set up this Public Inquiry so that 9 we can hear everybody who wishes to make 10 representations -- 11 MR GERRISH: I should not have to do this. I sent paperwork 12 to you and asked for you to see me. 13 THE CHAIRMAN: Let me finish what I was saying. One of the 14 disadvantages of everyone wanting to speak at the same 15 time is that we cannot actually hear what we need to 16 hear, and so if you are going to interrupt us like that, 17 it prevents the natural sequence of our hearing things. 18 If you have something that you want to put before 19 us, whether in writing or otherwise, you know that there 20 are established procedures, there are people here who 21 I am sure will happily talk to you and take it from you. 22 MR GERRISH: I have sent it to you in writing, and you have 23 sent it back. 24 THE CHAIRMAN: May I say the following to you: first of all, 25 it does not entirely help -- but I understand your 0103 1 intervening like this -- because it prevents us hearing 2 what we need to hear to get the picture. But I give you 3 this assurance: if you now were willing to talk to one 4 of my colleagues outside, we will take all the 5 particulars and I undertake now that we will look into 6 it and give you an answer in a very short time. Would 7 that be satisfactory to you? 8 MR GERRISH: Yes, I accept that. 9 MR LANGSTAFF: Sir, I wonder if I can just intervene, 10 because Mr Gerrish has on more than one occasion spoken 11 to me. I think one of the difficulties is that his 12 concern is principally with the death of his wife. One 13 of our difficulties, as the Inquiry, is that the 14 Secretary of State has set us up to enquire, as you 15 know, into the management of the care of children. By 16 definition, therefore, people whose treatment began 17 before and ended before 1984, or began and ended after 18 1995, and those who are adults, however justified their 19 concerns may be, are not matters which you, as an 20 Inquiry, can concern yourself directly with. 21 It may be -- this is where Mr Gerrish may have 22 very useful contributions to make -- that the insights 23 which he can give from his experience may help to 24 illuminate your terms of reference, but of course, we 25 cannot look at them directly. It may be that there is 0104 1 some misunderstanding as to that. That is why I rise, 2 simply to point out the difficulties that there are and 3 that there can be, whereas not wishing in any sense to 4 detract from the great advantage which any information 5 from Mr Gerrish and others will undoubtedly be to the 6 Inquiry. 7 THE CHAIRMAN: I am very grateful to you, Mr Langstaff. 8 Mr Gerrish, I do not, for a moment, wish to comment in 9 any way which would suggest that your grief and sense of 10 bereavement are not as strong as they clearly are. 11 Mr Langstaff has indicated that the Secretary of State 12 established terms of reference which we must subscribe 13 to, but he has also indicated there, I think very 14 helpfully, that there may be a room for you and my 15 colleagues in the Secretariat to continue to talk -- 16 MR GERRISH: You must remember that I went to the last 17 Secretary of State myself personally five times and he 18 ran away. William Waldegrave ran away from his 19 responsibilities. Had I done the same when I served my 20 country, I would have been shot for cowardice. 21 THE CHAIRMAN: Mr Gerrish, I absolutely understand, and you 22 will see that I am not running away; I am sitting here 23 now and hearing what you are saying. I am trying to 24 understand it and I am trying to feel with you how we 25 can find a way forward. 0105 1 May I suggest, therefore, that you take the 2 opportunity Mr Langstaff has offered, have some 3 conversations, and we can see what we can make of it. 4 I have been glad to see you in the hearing chamber 5 on a number of occasions, and I hope that as time goes 6 on you can see that we are beginning to move our 7 understanding forwards. Perhaps, therefore, with 8 Mr Langstaff, you could have a conversation. 9 Miss Grey, in the light of Mr Gerrish's wanting to 10 bring our attention to this particular circumstance, 11 this may be an appropriate moment just to take, shall we 12 say, a 20 minute break, and then, because I understand 13 that you are not intending to detain the witnesses very 14 much longer -- 15 MISS GREY: No. There is a very short series of questions 16 left, but I am conscious of course of the stenographers, 17 and also the fact that the Panel no doubt will have 18 questions to ask. 19 THE CHAIRMAN: Mr Langstaff may have something else he 20 wishes to say, so please forgive me, Miss Burr and 21 Mrs Jenkins. Miss Grey, is that satisfactory? 22 MISS GREY: It is. 23 THE CHAIRMAN: Shall we say therefore, it being now 12.45, 24 we will reconvene at about 1.05, and then I would 25 predict that we will go on until 2 o'clock at the 0106 1 latest. Thank you. 2 (12.48 pm) 3 (A short break) 4 (1.20 pm) 5 MISS GREY: Sir, may I apologise for the delay, the 6 slippage in the timetable? I apologise both to yourself 7 and to the witnesses, but it has enabled us to deal with 8 one or two things that have been arising. 9 THE CHAIRMAN: Of course. 10 MISS GREY: Before the break we were looking at 11 paragraph 12.6 of the RCN statement and discussing 12 confidentiality clauses and the experience that the RCN 13 had of the attempts to introduce them and their 14 introduction after 1991. 15 Can I ask you this: what dealings directly did the 16 RCN have with those members of staff who perceived 17 themselves as being potential whistle-blowers, to use 18 the phrase, and who were concerned about the 19 implications that might have if they spoke out? 20 MRS JENKINS: Can I start? I presume you want two specific 21 answers. 22 During 1990/91, the RCN launched a campaign about 23 whistle-blowing and produced in 1992 a document called 24 "Nurses speak out", which basically just was, if you 25 like, a check-list of what we believed should happen to 0107 1 try to prevent, as I was describing earlier, the need 2 for nurses to whistle-blow. I do not mean by that the 3 need for nurses to declare when things go wrong, because 4 quite clearly that is a duty that they have, but we 5 believe that there are, if you like, three main reasons 6 why this happens, why whistle-blowing happens. 7 It happens because, as I have said many times 8 already this morning, nurses hold a very dear remit to 9 themselves about protecting standards of care. It 10 happens because our code of conduct, the UKCC code of 11 conduct, actually tells us that we have a duty to speak 12 out if we think that either standards of care are not 13 adequate or if we think that the environment in which 14 our patients being looked after is not safe. 15 But probably, the reason that nurses whistle-blow 16 rather than speak is because they have tried other 17 methods that have failed, so in other words, they 18 whistle-blow when they get to the stage of believing 19 that they have tried to speak to their managers, they 20 have tried to get these things raised and they get 21 frustrated. That is why they tend to, if you like, go 22 public in a rather more dramatic way. That can cause 23 problems both for the Trusts, the nurses themselves, and 24 indeed the people they are trying to improve things for. 25 So we set up this campaign and encouraged nurses 0108 1 to speak out to us so that they did not necessarily have 2 to risk the sorts of problems that they could find 3 themselves in when they spoke out within their own 4 locality. 5 We had, over the next year or so, quite a few 6 people ringing us or writing to us and raising issues. 7 We did not have an overwhelming deluge of people, but we 8 did have some. I am not sure whether Sue has any 9 specific examples in terms of paediatrics -- 10 Q. Before you talk of specific examples, can I ask you 11 what you mean by "quite a few"? Are we talking tens? 12 A. We are talking tens, between launching the campaign in 13 1992 and over the next couple of years, so we had around 14 10 a year for those two years. 15 Q. Thank you. Sue? 16 MISS BURR: I do not have specific examples relating to 17 the specific whistle-blowing service that we ran, but 18 the situation of nurses feeling frightened to speak out 19 or feeling that they have been through all the local 20 management scenario in the appropriate way and nothing 21 is happening and they are seriously concerned, goes on 22 today. I mean, if you like, I could give you some 23 illustrations. 24 Q. Would you like to give us one, perhaps? 25 A. For example, a school nurse in a rural Trust where she 0109 1 was the only children's trained nurse in the whole 2 Trust, and it is a Trust with no acute paediatrician, 3 contacted me because she was aware of a plan to start 4 admitting people for a monthly ENT enlisted to a small 5 community hospital that had no facilities for children 6 whatsoever. I was amazed at what she had attempted to 7 do, including the health and safety check on the ward, 8 the letters she had written to management and with our 9 regional officer, he helped her with some of the letters 10 and we did not get any move from management. I even 11 have a letter in response to her concern that there were 12 not even any cots, that the parents could sit on the 13 beds with the children when they came back from theatre. 14 As they proceeded in the local level but were not 15 appearing to get anywhere, I did informally inform the 16 Nursing Officer in the government department that I was 17 aware that this was going on. 18 Then the situation that really was the crunch was 19 when the first list was undertaken and a local GP 20 anaesthetised the first two children. To me, that was 21 such a serious concern that I immediately went to the 22 government department. It is now that a consultant 23 anaesthetist must anaesthetise the children, but those 24 lists are still proceeding, even though the Health 25 Authority documents quite clearly said no children 0110 1 should be admitted to that hospital. 2 That nurse is in a situation where many of her 3 colleagues did not speak to her and now she will have 4 gibes like, "We are very short of money, but of course, 5 you making a fuss means now we have to pay for 6 a consultant anaesthetist". 7 That is the kind of era we are still living in 8 in 1999 on really quite serious issues. 9 Q. Does the experience of the RCN in initiating this 10 campaign, talking to nurses, tell you anything about the 11 barriers that nurses might experience in seeking to 12 raise concerns with doctors or with management when they 13 had such concerns? 14 MRS JENKINS: I do not know whether I can separate my 15 answer in terms of whether I am speaking as the RCN or 16 my own experience of having talked with individual 17 people, but I think the barriers are there and those 18 are -- again, we have talked about them in several 19 different ways. There is a feeling of helplessness, 20 a feeling that they may have tried to talk and no-one is 21 taking any notice; there is undoubtedly, or at least, 22 perhaps there has been in the past, not so much now, an 23 anxiety about security of jobs; that somebody who is 24 a trouble-maker can be replaced by somebody else. As 25 I say, that should be something that nurses do not feel 0111 1 quite so acutely now because there are so few of them. 2 When one is talking about nurses having concerns 3 about medical colleagues, there is a very real feeling 4 that those concerns will not be heard or acted upon. 5 That may be the case with other colleagues as well and 6 the one I mentioned when we were talking before lunch: 7 their concern that they may wish to talk out about 8 something that may not be a major area of fault but may 9 be a concern about somebody's health, and the systems do 10 not allow you to do that without a procedure sort of 11 clocking into place that rather moves the whole thing 12 into a disciplinary or more uncomfortable position than 13 the nurse may want. 14 Q. You mean that, for instance, within hospitals, the 15 system that might deal with ill-health on the part of 16 doctors would be something like the "three wise men" and 17 that will be too formal, too senior to deal with the 18 level of concern? 19 A. The concern is often demonstrated by a change in 20 practice or a change in behaviour which may be to do 21 with ill-health or depression or alcoholism or some 22 other quite treatable cause. It may not be total 23 incompetence to do the job. I think nurses may have 24 concerns that if they alert somebody to somebody's poor 25 practice, then these things will not be dealt with in an 0112 1 appropriate confidential sympathetic away and that the 2 person they are speaking out against may suffer in terms 3 of their own job. 4 All that goes back to my belief that if I can run 5 your organisation with a culture of openness and with 6 a culture of teamwork, where you can speak to 7 a colleague about somebody without feeling that the 8 whole thing is going to suddenly move off down a fast 9 track, then you can prevent these things happening. 10 Q. The second question was, do you think we have seen any 11 movement towards achieving that end, aspiration, across 12 the last 20 years? 13 A. Yes. In the last 20 years, thank you, that has made 14 it rather easier. I think it most definitely has. 15 There was an extremely good conference that I attended 16 at the King's Fund, I suspect about two years ago, which 17 was preparing for some work that the Medical Royal 18 Colleges were doing, I cannot quite remember what the 19 document was called, but it was called something like 20 "protecting good practice", or "ensuring good 21 practice", and I felt that in that forum of very senior 22 doctors and others speaking for the first time, there 23 was much more of an acknowledgment that we have 24 a responsibility to look after our staff just as much as 25 to look after our patients, and that most of the areas 0113 1 of poor practice are something you can do something 2 about, rather than the draconian methods that may have 3 happened earlier. 4 Q. That suggests that any improvement has been fairly 5 recent? 6 A. I think, from my experience, I would suggest that 7 that is correct. 8 MISS BURR: I think that certainly in relation to things 9 like health issues, issues, for example, drug 10 administration, in many cases has become less punitive, 11 but I am still very concerned how many nurses are very 12 concerned that if they actually identify where they 13 work, they will be seen as disloyal and it will go 14 against them in some way. I have a slightly biased view 15 because the people who contact me in the United Kingdom 16 as a whole are a very small number of people, but who 17 are concerned to take the matter further because they 18 have been advised they should not do so, they have often 19 been advised they should not speak to the RCN, and we 20 have found Community Health Councils and Action for Sick 21 Children particularly helpful because I then contact 22 them and give them the facts and they go in. So when 23 the nurse is sent for to be questioned, "How dare you go 24 to the Community Health Council?" she can say quite 25 honestly she did not know it existed or whatever, 0114 1 because I have been the one to do that. That is still 2 a common concern in 1999. 3 Q. If we turn to page 28 in your statement, we come to the 4 interim conclusions given by the RCN to the Inquiry. 5 Looking at paragraph 13.3 in particular, you describe 6 a number of historical factors that we have touched upon 7 over the course of this morning and afternoon. You 8 mentioned there also that one factor that distinguishes 9 the provision of child health services from others is 10 that the group of people affected, the children, lacked 11 a political voice of their own. 12 Should I take it from that sentence that the 13 Royal College of Nursing would agree or endorse the 14 Royal College of Paediatrics and Child Health's 15 suggestion that there should be a national commission 16 for children? 17 A. Yes, we do, and it depends -- I think there are various 18 suggestions of what you interpret by a "Commissioner for 19 Children", but somebody who is able to speak on behalf 20 of children, and we would go even further in that we 21 would like a Minister for Children to co-ordinate issues 22 relating to children across the various government 23 departments. We have a Minister for Women in the House 24 of Lords and the House of Commons for a long period of 25 time, and sub-committee of cabinet. We have nothing 0115 1 similar for children. 2 Q. Related to that is this question: over the morning we 3 have talked a great deal about recognising children's 4 voices and improving their position, and we have also 5 touched upon, briefly at least, the tension that there 6 may be with resource allocation and the fact that many 7 options for children may imply spending more money. 8 I realise that at least in part your answer to 9 some earlier questions was that that was not necessarily 10 so, and that important changes in practice could be 11 achieved without necessarily spending more money; 12 sometimes you could save it. 13 But there must be other developments that do cost 14 money. 15 Why is it that children's services should be 16 accorded a greater priority within the NHS, according to 17 the thrust of your evidence, rather than, say, other 18 contested services, geriatrics, mental health, many 19 other specialties, which would equally lobby for greater 20 resources? 21 A. I have never lobbied that children should have any 22 greater than any other group. What I am lobbying for is 23 that children, as any other client group, children are 24 a vulnerable group, as are care of the elderly, learning 25 disabled, the mentally ill, that they should have 0116 1 a particular priority within the Health Service, those 2 who are less able to speak for themselves, and are the 3 most vulnerable. I have never lobbied specifically that 4 children should have any more than anybody else, only 5 that they should have appropriate care, in some ways, if 6 you like, equal to that that adults have. 7 If you take children's community nursing, 8 a particular interest of mine, we have had a district 9 nursing service for adults for many a long year. We do 10 not have that throughout the United Kingdom for 11 children. I am only asking for a service relevant to 12 the children that I already have. 13 Q. So what you are saying is that you are coming from 14 a perception that there is existing an inequality of 15 provision and what you are looking for is equality of 16 provision? 17 A. Absolutely. I do not think it is just a perception. 18 I think there is a great deal of evidence that that is 19 true. 20 Q. If we just turn over the page, to page 29, 21 paragraph 13.5, you speak there about the development of 22 tertiary units and the case for greater specialisation 23 of care into centres of expertise. 24 The danger, perhaps, of specialisation, or 25 development of tertiary centres, or perhaps there is 0117 1 more than one, but one is the question of proximity to 2 a child's home. I know that Professor Baum has given 3 evidence to the Inquiry stressing the importance of 4 links between the family and the child and the 5 importance of maintaining those whilst in hospital. How 6 do you balance those interests when advocating the 7 development of tertiary centres? 8 A. I was totally supporting what Professor Baum says and 9 the importance of the links. I think it is having these 10 very overt and formal links. There are very practical 11 problems for families if the child is some distance away 12 from home. The expense of travel is one of those, and 13 Action for Sick Children and other voluntary 14 organisations contact the family, are very concerned and 15 have a campaign called "Too dear to travel", so there 16 are practical implications. If the facilities at the 17 tertiary unit are good for families, parents and 18 siblings, if there is clear communication, verbally and 19 oral, between the tertiary centre and where the child is 20 going back to or came from, with the community staff 21 including the GP so everybody knows where everybody is, 22 if the parent-held records are used appropriately so 23 that the families know explicitly what is going on -- 24 some units have very good shared care, so if you take 25 a child with cancer, they may have their initial 0118 1 treatment within a tertiary children's hospital, then 2 their care is shared with their district general 3 hospital. Not only are there agreed protocols and 4 policies, but they may develop some very good examples 5 of training videos where the staff from the district 6 general hospital are involved in making these with the 7 staff on the tertiary hospital, so that everybody has 8 the same information, whether you are at a tertiary unit 9 or at a local unit, and with the children. 10 The Action for Sick Children in Scotland did 11 a survey of their families as to whether they would 12 prefer to go to a tertiary centre for specialised care 13 or locally and overwhelmingly, they wanted to go where 14 the best care for their child was, at the tertiary 15 centre, if those other things were in place to assist 16 them. 17 Q. The cynic might say that the answer to that sort of 18 survey will depend very much on how the question is 19 worded, but if you imply that services will inevitably 20 be better at the tertiary centre, every parent will 21 answer that they want their child to have access to best 22 care? 23 A. Yes, we do have some evidence, some of the Clinical 24 Standards Advisory Group evidence points towards the 25 tertiary centre being able to provide better outcomes, 0119 1 and of course if they are talking about cost 2 effectiveness, if you group expensive equipment, 3 facilities and a whole range of staff -- I think we have 4 to remember some of these children, we are not just 5 talking about a doctor and maybe a range of nurses, 6 a whole plethora of people, with all different skills 7 and expertise, then that would seem to be appropriate. 8 I think the difficulty that the College has is 9 when parents think that they have a good service locally 10 and it might not be as good as they think it is. We 11 have that not in particular with tertiary centres, but 12 there are across the country now smaller children's 13 units, inpatient units being closed, and obviously it 14 depends on individual circumstances, but generally, the 15 Royal College of Nursing supports some of those closures 16 because the number of children, the range, et cetera, is 17 not appropriate for the children to be in those centres, 18 and better services can be provided for them more 19 distant from their home. 20 The difficulty is, how do you, without 21 frightening families, indicate that the service they are 22 having locally is not as good as it could be before you 23 have actually provided something at another service? 24 Unfortunately, a lot of these things get into 25 a political football and actually getting accurate 0120 1 information out is sometimes very difficult. 2 MISS GREY: Thank you. I have come to the end of the 3 questions that I wanted to ask. Before the Panel asks 4 questions, could I ask whether either of you have any 5 further observations that you would like to draw to the 6 attention of the Panel in today's evidence, remembering, 7 of course, that you do have every opportunity to put in 8 any further submissions, if you want to do that, at 9 a later date. 10 Mrs Jenkins? 11 MRS JENKINS: No, thank you very much. 12 MISS BURR: No, thank you very much. 13 MISS GREY: The Panel may have some questions. 14 THE CHAIRMAN: Mrs Maclean? 15 Examined by THE PANEL: 16 MRS MACLEAN: I would like to ask, Miss Burr, about PREPs 17 and PEPs, if I may. 18 We heard yesterday from the UKCC. In their 19 written evidence they gave us extremely helpful 20 information about their commitment to post-registration 21 education, which is of great interest to us as an 22 accreditation and continuing registration function, and 23 as part of that programme, they described to us the 24 inclusion of portfolios of current work and educational 25 conferences attended and so on. 0121 1 You told us a little this morning about your 2 forums and how these can be used for professional 3 education points. 4 I am very interested in the way that these 5 two functions are linked together, and I wonder if you 6 could tell me a little more about how PREPs and PEPs 7 work together? 8 MISS BURR: In relation to most of our conferences, there 9 is a process in which the speakers are required to put 10 what their objectives are, the learning outcomes, 11 appropriate references, et cetera. That is then 12 scrutinised by our Institute of Education for them to 13 get appropriate accreditation of a number of points that 14 is thought appropriate. So that is done by our 15 educational people. 16 Within the portfolio, a lot of nurses sometimes 17 have difficulty in recognising that it does not mean to 18 say that you have to go to conferences or you have to go 19 to courses. The important thing is you think about what 20 you want to achieve from that learning and reflect upon 21 it. So, for example, I have suggested to some of our 22 members that they should think of attending the Inquiry 23 as a part of their portfolio, because if they thought of 24 their objectives beforehand and reflected on it, I think 25 that would be a very important educational opportunity 0122 1 on perhaps a very different aspect to what they had 2 thought of. The same as you may be wishing to write 3 some information for families and you might wish to go 4 and visit some families through one of the voluntary 5 organisations, linked with another -- obviously the 6 major children's hospitals have far more in the way of 7 what I call "back-up" staff so they would have excellent 8 maybe paediatric social work departments or something 9 like that, but if you are a small unit, you do not have 10 that plethora of people who are focused on the child. 11 So linked with your regional centre, they may have 12 already produced that information; you want to adapt it 13 to yourself, and you can use it again in your portfolio. 14 On a more formal level, the Royal College of 15 Nursing was the first institution to provide a BSc in 16 Child Health Nursing, we now have a Masters, and last 17 September we put this into a distance learning mode, 18 which I was particularly keen to do because if you are 19 not working in a major city, the likelihood of you 20 having educational opportunities in children's nursing 21 to degree level are somewhat remote. We did have nurses 22 coming from Newcastle down to London to attend our BSc 23 and Masters in Child Health Nursing. Now we have been 24 able to put this into distance learning mode, it should 25 be that children's nurses, in even quite a small unit, 0123 1 should be able to access updating, further development, 2 in their particular aspect of care. 3 Does that answer your question? 4 Q. Thank you very much. That is very helpful. Could 5 I perhaps ask Miss Burr if she has anything to add on 6 the relationship between what you have just been 7 describing to me, which is very much the cutting edge 8 and the development side of specialist education, as 9 opposed to the UKCC function which is registration, 10 which in a sense is perhaps not at the cutting edge in 11 the same way? Is there a tension between these two 12 functions? 13 MRS JENKINS: No, not at all. Every nurse has to 14 re-register every three years and any minute now -- 15 I think actually now, as of this year -- the next time 16 we have to register, any one of us, we will have to 17 demonstrate or we will have to be able to prove, if 18 asked, that we have undertaken enough education during 19 that period of time to make re-registration possible. 20 I think the important thing to be clear about, 21 about the RSCN's continuing professional development -- 22 which just to confuse things even more we call CEPs, 23 continuing education points -- is that they are not 24 a valid currency: they do not buy you anything; you 25 cannot trade them for something. They are equivalent 0124 1 to a period of study and as the UKCC's way of 2 re-registration is to ensure that your whole portfolio 3 of experience is good enough, then they are a very good 4 way that nurses can demonstrate that they have 5 undertaken a period of time. 6 So, for instance, during our week long Congress, 7 you could probably clock up quite a lot of CEP points 8 which would give you probably the equivalent of what you 9 would require to demonstrate that you had undertaken the 10 appropriate study and reflection. 11 MRS MACLEAN: Thank you very much; that is very helpful. 12 THE CHAIRMAN: Mrs Howard? 13 MRS HOWARD: Just one point. It is most probably addressed 14 to Miss Burr. It relates to the issue of sharing good 15 practice, providing support for people in isolated 16 practice particularly, and I wondered whether the 17 College had a comment about the model that was described 18 within the paediatric intensive care document in respect 19 of lead centres and their responsibilities for providing 20 that level of support for people in some form of 21 isolated practice. Perhaps we could take that further 22 and perhaps look at the role of a specialist Children's 23 Hospital and its responsibility for providing support 24 for isolated practice. 25 MISS BURR: Yes, I would support the model as it is 0125 1 within the Department of Health guidance, and I could go 2 further than that. I think we went through a difficult 3 time with the competitive Trusts, and some of the Trusts 4 felt that they were not able to help their district 5 general hospitals within their region because their 6 Trust contract did not allow them to do so. 7 I also think in the past there was quite 8 a situation within children's nursing from some of the 9 children's hospitals that they were the best, many of 10 their staff had never worked anywhere else and that they 11 did not really feel they had any responsibility to help 12 anyone else. 13 I have to say that I have seen in the last five 14 years a dramatic change in that, and certainly, some of 15 our major children's hospitals have produced documents 16 which they are able to produce -- I can think of one to 17 do with child protection in acute units -- and they will 18 sell it for 5, which, for a small unit in a district 19 general hospital, has been an absolute -- I cannot think 20 of an appropriate word but it has been wonderful to 21 them, because they do not have the resources to produce 22 that kind of document, and in fact to actually even 23 persuade their managers they need that kind of document 24 has been very difficult. Now some of the hospitals are 25 seeing that as helpful. 0126 1 I can give a very recent example, in a situation 2 in a very isolated area, an island in the north of 3 Scotland, where one children's nurse who has gone to 4 live with her husband who has a job there, there is no 5 paediatrician, is horrified they do not even have 6 appropriate charts for children in hospital, and whereas 7 originally she contacted the nearest Children's Hospital 8 which is many miles away but just spoke to a ward sister 9 who said "I cannot send you any charts because it is 10 Crown property and our property", she contacted me, 11 could I help? I rang the Director of Nursing who not 12 only has been very keen to share their charts et cetera 13 with them, but has included her in their mailing list, 14 invited her to conferences. 15 That I see as being extremely helpful. I think 16 that is something where the College has been able to do 17 a great deal. I am not the person who knows it, but 18 I am the person who knows somebody else who does know 19 it. I see that as spreading and I very much hope that 20 will be encouraged. The difficulty of course for major 21 children's hospitals is that they do not have any 22 financial assistance to provide that to other hospitals, 23 yet it is a cost-effective way of getting continuity. 24 Certainly within a region, I always say to the 25 nurses in the district general hospital, "Where do you 0127 1 send your sick children?" because I think for families, 2 if there is some continuity between the local hospital 3 and the tertiary centre, and that they feel that they 4 are working together, I think that must be very 5 comforting to families to feel that they are all working 6 together for the sake of the child and the family. 7 MRS HOWARD: Thank you very much, very useful. 8 THE CHAIRMAN: Professor Jarman? 9 PROFESSOR JARMAN: Miss Burr, you have mentioned the lack of 10 evidence about whether children's nurses make 11 a difference. I agree it would be very helpful to test 12 your hypothesis, if you like, because it would help you 13 to establish what you are trying to get. 14 The question is, do you know if there are any 15 regular recorded data about the numbers of children's 16 nurses in each Trust, so one could start looking into 17 this? 18 MISS BURR: My understanding is that there is not, because 19 Trusts are usually able to record the staff from their 20 payroll, and whereas nurses who have additional -- for 21 example, the psychiatric lead and the geriatric lead, as 22 they are called, they are able to identify them. Many 23 Trusts are not able to identify how many children's 24 nurses they employ, or where they employ them. 25 I think there is another difficulty here. In 0128 1 the past people have thought of employing registered 2 children's nurses only on the children's ward. They 3 have not thought about them in the children's 4 outpatients, in the Accident & Emergency Department, in 5 the intensive care or in the community. 6 Certainly when I was a health visitor I felt 7 I used my children's training the whole time, but that 8 that would not be then thought of as a place 9 specifically where you should have a children's 10 training. 11 So I think it is quite difficult. 12 The UKCC of course knows how many children's 13 nurses are registered with it, but it does not know 14 whether they are actually working and it does not know, 15 if they are working, are they working with children, and 16 again we have that interpretation of, "What do you mean, 17 are they using their skills?" because if they are not in 18 what is designated a children's area, you may think they 19 are not, but if they were working in an Accident and 20 Emergency Department, they would the whole time be using 21 their children's skills whenever there were children 22 there. 23 PROFESSOR JARMAN: Thank you. Mrs Jenkins, you said: 24 "We believe that nurses have been perhaps more 25 involved and interested in the quality of care than 0129 1 other professional colleagues". 2 I wonder if you could mention which professional 3 College you were thinking of? 4 MRS JENKINS: I have to be careful with the answer to that 5 one. It is quite clear that the medical profession has 6 I think -- I guess always -- taken quality seriously, 7 but I would have to say that the way they do it is 8 rather different. It is a rather more specific and 9 often more -- I probably will get the wrong words here, 10 but diagnostic and treatment based, whereas I think what 11 nurses look for is that roundness of quality of care 12 that starts, you know, before the patient has left home 13 to come to the hospital for their appointment or 14 operation or treatment or whatever it is. 15 Nurses I genuinely believe, because they spend 16 more time with patients in so many different settings, 17 have got that broader knowledge of the various aspects 18 of healing, if you like, that are not just about the 19 medical care -- and I am not in any way making 20 a criticism or even a judgment about who does what best; 21 I just think that nurses tend to think more about 22 whether a child has left his teddy bear behind or is 23 worrying about whether Mum is going to be able to get 24 home in time to make the brother's supper, than doctors 25 do, because doctors are more focused in my view, in, as 0130 1 I say, the very necessary care of clinical, diagnostic 2 and treatment that tend to surround most of their time. 3 PROFESSOR JARMAN: Thank you. Mrs Jenkins, Miss Burr, 4 I have no questions. Is there any re-examination? 5 MRS STOCKLEY: There is no re-examination, thank you. 6 THE CHAIRMAN: Miss Grey stood up and I was looking over 7 there, but I received an answer. I am grateful, thank 8 you. 9 Mrs Jenkins, Miss Burr, we are immensely grateful 10 to you for coming to talk to us today. Today's evidence 11 has taken us back, as will be clear, to Block 2 of what 12 we are concerned with, namely setting the national 13 context in which any particular examination of what 14 transpired in Bristol must be set. 15 We are very grateful for what you have been able 16 to do in terms of paint the picture from the point of 17 view of the Royal College of Nursing and particularly in 18 the context of paediatric nursing, and we have been very 19 greatly assisted. Thank you very much indeed to both of 20 you. 21 May I impose on you for one more minute and ask 22 you to remain seated for just a second while 23 Mr Langstaff has something to say to me -- you want to 24 say something? 25 MRS JENKINS: On behalf of the RCN, Sue and I would really 0131 1 like to convey our sincere sympathy to the families of 2 the children that died, but also we would like to convey 3 our recognition to the staff that worked with those 4 children, because we recognise the anxiety and stress 5 that they must have been going through then, and are 6 probably going through even now. We are really grateful 7 that you have given us the opportunity to express our 8 passion for nursing and our commitment to patient care. 9 Thank you very much. 10 THE CHAIRMAN: Thank you. Mr Langstaff? 11 MR LANGSTAFF: Sir, this being the last evidence for the 12 day, this would normally be the occasion when we would 13 adjourn for the week and, indeed, for the fortnight 14 because we do not begin again until the 5th July, 15 hearing evidence. 16 I was told at about 1 o'clock, just before the 17 last break that we had, by Mr Lissack for the Action 18 Group, that he wished to make an application, and as you 19 know, it is part of the procedure of the Trust that any 20 application to be made can be made at the end of the 21 day. 22 Having discussed the nature of that application 23 in very general terms with him, it is plain that it is 24 right that the Trust should be in a position to respond 25 if need be to what is or may be said. 0132 1 For that purpose, I shall invite you to adjourn 2 for a few minutes until Miss Austin, the solicitor for 3 the Trust, is able to be here to apprise herself of the 4 details of what it is proposed may be said and to 5 respond to it. 6 Sir, that is the first point. 7 I have two further things which I should say: 8 again, shortly before lunch when everything seemed to be 9 happening, Mr Gerrish, as you will remember, 10 intervened. Can I simply say that I have been told that 11 Mr Whitehurst, the solicitor to the Inquiry, has spoken 12 to Mr Gerrish and the upshot is that he will be in 13 correspondence with Mr Gerrish, and we hope that may 14 take matters forward to his and to the Inquiry's 15 satisfaction. 16 Thirdly, it is perhaps right, since the 17 application will undoubtedly be of a formal procedural 18 nature, it will of course be on the Internet, as is 19 this, but for those present today or those who may be 20 watching at a remove and who may not be as interested as 21 others in the application that is to be made, whenever 22 it is to be made, that I should say something about the 23 programme for the week beginning 5th July. 24 We return, then, to deal again with Block 3 of 25 the evidence. It is important that I should emphasise 0133 1 that we are looking at Block 3 of the evidence because 2 the first witness on both Monday 5th and Tuesday 6th 3 July will be Mr James Wisheart, and because of the 4 prominence which his name has assumed in much of the 5 evidence we have heard and much of the publicity before 6 this Inquiry was established, it again may be thought in 7 his case, as it might have been thought in the case of 8 Dr Roylance who gave evidence a week or so ago, that he 9 might be asked on 5th or 6th July about matters which 10 led directly to the setting up of this Inquiry. 11 He will not, at this stage, be asked about the 12 clinical care which he, and for that matter others, 13 provided to individual children or children generally. 14 The purpose of his evidence at this stage is to deal 15 with his management, and the management, and what he can 16 tell us about the management, by him and others, of the 17 care of children in the hospital with which we are 18 concerned in this Inquiry during the period of our terms 19 of reference. 20 It needs to be emphasised, for those who are 21 picking this up at a distance, that the scope of the 22 investigation which will take place, the scope of the 23 questioning, the scope of the answers, will be limited 24 and it must not be thought either on the one hand that 25 the Inquiry is not asking the obvious questions which 0134 1 those beyond these walls might wish us to ask, because 2 they will be asked, but just not at this stage. 3 Equally, it must not be thought that this evidence 4 is of any lesser importance to the Inquiry. 5 Sir, that is likely to occupy us on 5th and 6 6th July. On 7th July we will hear from 7 Dr Marie Thorne, whose evidence again we have 8 anticipated a bit by looking at papers she has written 9 in respect of her analysis of the style of management in 10 the Trust in the early years of the 1990s. 11 The Thursday of that week is not yet confirmed; we 12 have a very good idea, I think, of the witnesses who are 13 likely to be coming, but because confirmation has not 14 yet been received, it would be unjust of me on behalf of 15 the Inquiry to identify their names at this stage. It 16 is two weeks away, and the identities will be posted in 17 the usual way electronically on the Internet and through 18 our publicity machine well before the time they come to 19 give evidence. 20 Sir, those were the three matters for which 21 I wished to detain you. I would ask you now to adjourn 22 until we are in a position to hear the application, and 23 may I, for my part, apologise to Mrs Jenkins and 24 Miss Burr for having detained them to have to listen to 25 me for so long at the end of the week. 0135 1 THE CHAIRMAN: Thank you, Mr Langstaff. You gave me the 2 guidance of only "some minutes". May I, therefore, 3 suggest 30 minutes? Is that an inappropriate time? 4 MR LANGSTAFF: That looks about right. May I liaise with 5 you through the usual channels if there should be any 6 further delay? If we say 30 minutes. 7 THE CHAIRMAN: I join you in apologising to our two 8 witnesses and thanking them again. We will now adjourn 9 and will reconvene in half an hour, that is, at 2.40. 10 (2.12 pm) 11 (Adjourned until 2.40 pm) 12 (2.45 pm) 13 THE CHAIRMAN: Mr Langstaff? 14 MR LANGSTAFF: Sir, as I had anticipated some 40 or so 15 minutes ago, there is to be an application by 16 Mr Lissack. 17 APPLICATION BY MR LISSACK 18 MR LISSACK: Sir, thank you very much indeed for letting me 19 make this application this afternoon. The UBHT have 20 today produced to the Inquiry three box files of 21 material relevant to issue J, the issue of postmortem 22 autopsy and the retention of organs removed during 23 either procedure. 24 I am told, and of course fully accept, by 25 a solicitor on behalf of the UBHT that in providing that 0136 1 material, they have fulfilled the request of them by the 2 Inquiry for the provision of data that they hold. 3 We wish to apply to you, sir, to invite the 4 Inquiry to use its statutory powers to compel production 5 of any material which is not hitherto provided and which 6 now appears relevant, unless, of course, you receive the 7 assistance of voluntary production immediately. 8 The reason we make this application is for two 9 reasons. The first is this: that the Inquiry programme 10 should not be dislocated by the late provision of 11 important data if that can be avoided. 12 The second reason for us making this application 13 is that this sensitive issue must not, in our respectful 14 submission, be taken before all parties, and principally 15 my lay clients and those who represent them, are ready 16 to assist you. 17 May I explain the timing of this application, 18 because I said that I would to Mr Steven Miller, and 19 indeed, in his absence? I make this application today 20 because other professional commitments permitted me to 21 be here and it coincided with production of the 22 material. I did not actually arrive here intending to 23 do this, but it appeared to be convenient and you were 24 good enough to hear it. So Mr Miller is not here and he 25 will read that I have now explained why he is not here, 0137 1 because he did not know I was going to say it. 2 Otherwise, out of a sensitivity which perhaps does him 3 credit -- he will judge for himself whether it does -- 4 he would have been here to address you, but there we 5 are. That is done, so I have honoured what I said 6 I would say. 7 The Inquiry's timetable on this issue is for 8 evidence in the weeks of 12th and 19th July, and we are, 9 I underline, very anxious that that timing is not 10 imperilled by late disclosure. But Mrs Michaela Willis 11 and other members of the BHCAG due to give evidence on 12 this issue, have indicated in writing through their 13 solicitors to the Inquiry that they will not sign their 14 statements or intend to give evidence unless they are 15 satisfied there has been full disclosure to the Inquiry 16 and they have had an opportunity to prepare a full 17 response and submission upon the information. 18 There are seven issues which I will shortly list, 19 and then I am done, upon which this material may tell. 20 (1) Where the postmortem carried out was 21 authorised by the coroner, whether or not there was 22 consent and if so the circumstances in which that 23 consent was obtained, is of importance. 24 (2) Where there was an autopsy carried out with 25 consent, the circumstances in which the consent was 0138 1 obtained. 2 (3) Where there was an autopsy without consent, 3 how it came to be carried out at all. 4 (4) Why and with whose consent were organs 5 removed? 6 (5) Why, and with whose consent, were organs 7 removed simply thrown away? 8 (6) Why and for what purposes was information 9 concerning the autopsies held by Professor Berry? 10 (7) Why was the truth kept from my clients for in 11 some cases up to 25 years or more? And why was it 12 eventually told when and how it was in early 1999? 13 I am very much assisted by having had discussions 14 with Mr Langstaff over the last couple of weeks about 15 this, and I know you will understand this is not an 16 issue we take in criticism of the Inquiry or anything of 17 that sort, quite the contrary. We only mention it 18 because we do not want the Inquiry in any sense taken by 19 surprise by some grandstanding speech at the last minute 20 saying "We are not coming to give evidence today, we are 21 off to do this in another fashion". But equally we want 22 the Inquiry to fully understand that our lay clients are 23 deeply troubled by this issue, as you can well imagine, 24 and it is a matter of significance not just in the 25 Bristol context but perhaps nationally as well. 0139 1 May I also, whilst I am here, tell the Inquiry 2 that we have collated a very large amount of information 3 which we have passed to the Inquiry and will continue to 4 do so as it is updated, on this very issue, and the 5 statistics that I shall give you so they are on the 6 record, as at today's date, are the result of an 7 enormous amount of hard work for the Inquiry by the 8 Executive of the BHCAG and Mr Lawrence Vick and his 9 research team. 10 The information we have present is this: of the 11 116 parents who have responded to the request for 12 information concerning autopsy and/or postmortem, 112 of 13 them had children who were subject to one or other of 14 those procedures, so only 4 out of 116 were not 15 postmortemed or autopsy examined. 16 Of those 112, in 109 cases -- so 97.3 per cent, 17 I am told is the calculation -- were organs retained. 18 In 28 of those 109 cases, we know that some or all of 19 the retained organs were subsequently disposed of. 20 In 88 of the cases, 80.7 per cent, some or all of 21 the removed organs were retained, and as I say in some 22 instances, stretching back from the information we have 23 been given as far as 1972, and to date, since the Trust 24 made known the state of affairs 9 parents we know of 25 have so far reclaimed their child's retained organs. 0140 1 In the vast majority of the cases in which organs 2 were removed during postmortem, the child's heart was 3 taken and indeed only three instances of postmortem 4 removal do not include the heart, but in addition to the 5 heart, there is a very large range of other organs 6 taken, so one only has to consider the statistics 7 without any embellishment upon them, and I will not give 8 any, to see the importance of being ready so far as our 9 clients are concerned. 10 I am very pleased to be able to tell you in the 11 moments since you last rose and kindly came back in 12 again to hear what I have had to say, we have had the 13 chance to discuss the position further with the 14 solicitor on behalf of the UBHT, who has very helpfully 15 said that if we wish to identify on a named basis the 16 individual members of the group that I represent and ask 17 that their individual records are produced, they will 18 use their best endeavours to do so. I am very grateful 19 for that. 20 Also, Mr Langstaff was good enough, when we were 21 all talking before, to suggest that perhaps some other 22 information that they hold, principally some 23 computerised records held by Professor Berry as to the 24 issue generally, should be provided to the Inquiry so 25 that we can all see it. 0141 1 That is all very constructive and as it should 2 be. My only concern remains that the longer it takes to 3 get, with the best will in the world, the more difficult 4 it may be to deal properly with the issue. 5 That is all that I want to say, but I stress that 6 what I say is in the sense of being constructive rather 7 than critical and destructive. 8 THE CHAIRMAN: Absolutely. That is understood and 9 accepted. I am immensely grateful to you, Mr Lissack. 10 Does Miss Austin want to come forward, please? 11 RESPONSE BY MISS AUSTIN 12 MISS AUSTIN: Sir, thank you. There is not much else I need 13 to say, except to underline that my clients are very 14 alert to the importance and the sensitivity of this 15 issue, not only to the parents directly involved, but 16 also in the sense of being of national interest. 17 As Mr Lissack has been kind enough to say, we 18 have today produced to the Inquiry documentation which 19 is exactly what we have been asked to produce. I have 20 also indicated to the Inquiry through your solicitor, 21 sir, that there is other documentation which is specific 22 to individual patients and that includes, in that sort 23 of umbrella, the computerised information Professor 24 Berry holds. If we are asked for it, we will be very 25 happy to produce it, but so far we have not been asked 0142 1 for it. We will produce that either in its entirety or 2 on a sort of individual named patient basis, if there 3 are particular individuals who wish to have their cases 4 looked at or to see their records as opposed to the 5 Inquiry wishing to see all of it. Whichever way, we do 6 not mind and we are very happy to produce it as soon as 7 we can, just as soon as we are asked. 8 I think that is all that I need to say, apart from 9 the issues that Mr Lissack has raised which are set out 10 in the Inquiry's Issues List. We are alert to them, and 11 I can give the Inquiry our assurance that they are all 12 questions that are being addressed in the witness 13 statements and the evidence that you will be hearing, 14 hopefully in July, if everybody feels ready then. 15 Thank you, sir. 16 THE CHAIRMAN: Miss Austin, I am grateful to you, not least 17 for having to get here and talk to us. Thank you. 18 Mr Langstaff, advise me, please. 19 REPLY BY MR LANGSTAFF 20 MR LANGSTAFF: Sir, may I deal with the formal matters in 21 just a moment, but perhaps it is right that I should say 22 that no-one would, I think, be human if they did not 23 recognise that issue J is perhaps one of the most 24 emotive and difficult issues for anyone to deal with. 25 For my part, I would wish to pay tribute to the legal 0143 1 representatives who have, indeed, as they have said, 2 been speaking to the Inquiry over the last week or so 3 for the way in which they have handled what is obviously 4 a very difficult and delicate issue for anyone, let 5 alone their clients, whoever they may be. 6 So far as the formal aspects are concerned, you 7 have I think an application which, as I understand it, 8 does not require any action or order today. It is, 9 I think, perhaps a reflection of the fact, as 10 I understand it, that Mr Lissack's professional 11 commitments meant that if he were to make the 12 application, he would have to do it today as we are not, 13 of course, sitting next week. I would ask you, 14 therefore, to regard it as a potential application, 15 reminding you of your powers, and asking you that if any 16 occasion arises when it would seem that you might 17 exercise your powers, you should do so. You are invited 18 to do so. There has been no disagreement to your doing 19 so by Miss Austin, and you should do so without any 20 further delay or without the need for a further hearing. 21 I think that is the nature of the application. 22 That will be the advice that I would give to you. 23 So far as the facts are concerned -- 24 THE CHAIRMAN: May I just interrupt you for a moment? 25 I took it from Mr Lissack that he was really 0144 1 suggesting -- I may be wrong -- that given the timetable 2 which he rightly draws our attention to, there was 3 a point at which any relevant material should be made 4 available if we are to go forward. I did not hear 5 Miss Austin in any way resist that. Therefore, I would 6 like your advice and the advice of those behind you as 7 to whether you can agree without my specifying 8 a particular time or a particular schedule, or if you 9 want a specified date. 10 There is a further issue which I think Miss Austin 11 does raise, which arises from what Mr Lissack was 12 saying, that some of the information which was being 13 talked about is specific to particular parents who may 14 not want it in the public domain and it is clearly 15 a matter for them to choose. It will be their right 16 whether they want to be in the public domain. There are 17 other disks, as I understand it, which may be of 18 a general nature and which would perhaps assist this 19 Inquiry. So, again, there needs to be, as I understand 20 it, a discussion -- and perhaps I am saying things that 21 you were going to tell me and if I am, forgive me and 22 put me right where I am wrong -- there would need to be 23 discussion behind you so as to separate those two items. 24 Have I got it right, or were you going to advise 25 me something different? 0145 1 MR LANGSTAFF: You have, of course, got it right, but may 2 I perhaps add to it in this way: I think putting -- 3 I have not yet had the advantage of consulting behind 4 me, but I think there may be a difficulty of putting 5 a date as such upon it because much depends upon the 6 exact nature of the information that we have received -- 7 and we received, in fact after Mr Lissack first came to 8 the Inquiry but before the application was made, we have 9 not yet of course had any opportunity to look at it, 10 analyse it and most important, to make sure that nothing 11 which needs to be kept confidential in the interests of 12 patient or parent confidentiality, is disclosed. 13 Those processes have to be done by the Inquiry. 14 I would hope that in the same way that everyone thus far 15 should, we Trust, be satisfied with the way in which the 16 Inquiry has obtained documents and dealt with them, that 17 they will, in the event, be equally satisfied that we 18 have all the documents which pertain to this particular 19 area. 20 May I say that during this past week we have had 21 full co-operation from both the Parents' Action Group 22 and from the Trust. The Parents' Action Group, through 23 Mr Lissack, raised concerns. We have explored those 24 concerns. We were told by the Trust that the documents 25 would be delivered today before the close of business. 0146 1 They have honoured that commitment. It may look like 2 coincidence that they arrived at the same time, as it 3 were, as Mr Lissack did to make the application, but 4 that was the promise they have made and they have 5 honoured it. We have no reason to think that any of the 6 promises made on either side as to disclosure will not, 7 in fact, be honoured in the event. 8 May I also say that today again I have been given 9 by Mr Lissack very helpful summaries of information 10 which the Action Group have plainly spent a lot of time 11 and effort preparing, which you, I feel sure, will find 12 most helpful to the Inquiry. He has indicated in the 13 course of his address something of the nature of that. 14 It may also be the case, if I can just add, that 15 in the course of the next week or so, if I should be 16 advised by the Secretariat or by the legal team that 17 there is any witness not, I hasten to add, a parent, nor 18 anyone under the wing of the Trust, who we would wish to 19 come before you to give evidence who is reluctant to do 20 so, that I may well come to you and invite you to use 21 your power of subpoena, which I would hope you would 22 feel able to do. 23 There is only one matter I should comment on: that 24 Mr Lissack has said, rightly, that shortly before you 25 came in I ventured to Miss Austin that the Trust might 0147 1 give the Inquiry, now that the general documents have 2 been delivered, disclosure of the computer records, the 3 hard disks and so on, which contain information which is 4 patient specific. It needs to be emphasised that of 5 course that information cannot just simply be put, if it 6 comes to the Inquiry, into the public domain, because it 7 being patient-specific -- I did not intend anything 8 different, but he did not say that of course that is 9 subject to confidentiality. It is and has to be, and we 10 have set ourselves high standards of confidentiality 11 which in this in particularly emotive area, we would 12 wish to maintain as scrupulously as we have, we hope in 13 others. 14 Sir, that is I think only adding to that which 15 you have already said and unless there is any more from 16 behind me -- I will check in a moment -- that would be 17 my advice to you. 18 THE CHAIRMAN: I would be grateful if you were able to 19 check. (Pause). 20 MR LANGSTAFF: As I say, perhaps, the only final comment 21 I would have is to repeat my gratitude from where 22 I stand for the way in which the representatives of all 23 parties have been able, amongst ourselves, to deal with 24 a difficult issue without the rancour that there might, 25 in some circumstances and between some other people, 0148 1 have been present. 2 THE CHAIRMAN: Mr Langstaff, I am very grateful. 3 Mr Lissack, do you want to add anything, or are you 4 content with what we seem to have agreed? 5 MR LISSACK: Very content indeed. Thank you very much 6 indeed for letting us air it. 7 THE CHAIRMAN: Not at all. I join Mr Langstaff in 8 expressing the Panel's thanks to the various legal 9 representatives. I have been aware there were 10 conversations, although of course I was not privy to the 11 detail. I am very grateful to all of those, to have 12 been able to take what is an extraordinarily difficult 13 issue forward in such a sensible and sensitive way. On 14 behalf of the Panel, I express my appreciation. That is 15 how we all conceive this Inquiry proceeding and with 16 your co-operation it is proceeding. So thank you all. 17 We adjourn now. Next week is a reading week, so 18 we reconvene on Monday 5th July at 10.30. 19 (3.10 pm) 20 (Adjourned until Monday 5th July at 10.30 am) 21 22 23 24 25 0149 1 I N D E X 2 3 MRS LIZ JENKINS (Affirmed) 4 and 5 MISS SUE BURR (Affirmed) 6 Examined by MISS GREY ........................ 2 7 Examined by THE PANEL ........................ 121 8 9 APPLICATION BY MR LISSACK ......................... 136 10 RESPONSE BY MISS AUSTIN ........................... 142 11 REPLY BY MR LANGSTAFF ............................. 143 12