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  1. This is a Consultation Note on Phase Two of the Bristol Royal Infirmary Inquiry.

  2. The Inquiry’s terms of reference are:
  3. "To inquire into the management of the care of children receiving complex cardiac surgical services at the Bristol Royal Infirmary between 1984 and 1995, and relevant related issues; to make findings as to the adequacy of the services provided; to establish what action was taken both within and outside the hospital to deal with concerns raised about the surgery and to identify any failure to take appropriate action promptly; to reach conclusions from these events and to make recommendations which could help to secure high quality care across the NHS."


  4. In his opening statement to the Inquiry’s preliminary hearing on 27th October 1998, the Chairman explained that the Inquiry would be in two phases. Phase One, currently underway, is examining paediatric cardiac surgical services at the Bristol Royal Infirmary and the Children’s Hospital. Phase Two, due to commence early in the year 2000, will be an examination of relevant wider issues.
  1. The objectives of Phase Two will be:
  2. a. to assist the Inquiry Panel in meeting the requirement in their terms of reference, "to make recommendations which could help to secure high quality care across the NHS";

b. to help to ensure that the Inquiry’s recommendations are relevant to the NHS of the future, practical and achievable, all within a realistic level of resources.

Purpose of this note

  1. This note sets out for consultation the proposed themes for examination in Phase Two. It also suggests how Phase Two might be organised. The BRI Inquiry welcomes comment on the proposals in this paper and in particular on the suggested themes; possible seminar topics within the suggested themes; and the organisations or individuals who might be invited to contribute papers on specific issues. Contact details for comments are given at the end of this paper.
  2. The approach to Phase Two

  3. In the second phase of the Inquiry, the Panel intend to focus on examining such current and potential future policy initiatives as could help to improve the quality of care in the NHS. The Panel intend to take a national perspective, informed by learning from the evidence presented in Phase One of the Inquiry.
  1. As with Phase One, Phase Two will require written papers, which the Panel will commission from a wide range of organisations and individuals. The papers, which will be published, will be supplemented with a series of eight to ten public seminars, in the same way as the Phase One written evidence was supplemented by oral hearings.

  2. The approach to Phase Two will be wide-ranging, and wherever it is likely to be of significant assistance, the Inquiry will invite papers and contributions from outside the healthcare sector, and from individuals and organisations outside the UK.

    Themes for Phase Two

  4. Seven themes have been identified for Phase Two and are listed below, each with suggested sub-themes, in no particular order. There is obviously some overlap between the themes, and some debate as to where the sub-themes might most appropriately fit. Indeed different aspects of the sub-themes are relevant to different themes. Comments are invited on the suggested themes and sub-themes.

Theme One: Children in the NHS

This theme concerns the issue of the quality of children’s healthcare and health services; it could cover:

  • Priority accorded to children’s healthcare and health services.
  • Paediatrics as a specialty (medical/nursing/surgical).
  • Needs and rights of children and parents/guardians, including communication on:
  • who is responsible for care/treatment of an individual child;
  • risk of procedures, including explanation of methods used, information given, to whom and by whom;
  • consent to procedures, post mortems, and tissue retention.
  • Support for parents/guardians and children, including counselling.

Theme Two: Aiming for quality in the NHS

This theme addresses the ways of achieving better quality services in the NHS:

  • What makes a "safe" organisation? The role of risk assessment and risk management, and responsibilities for these activities.
  • The role of standard setting and of the monitoring and enforcement of standards; and responsibilities for these activities.
  • Accountability and responsibility in large, complex organisations.
  • Appropriate working patterns – staffing levels, management structures, concept of the clinical team.
  • Patients and carers – what they want and need from the NHS – understanding patients’ requirements, both local and national.
  • Clinical governance and other relevant policy initiatives.
  • Respective roles and responsibilities of various professional and managerial groups (including health authorities, Primary Care Groups, Royal Colleges, regulatory bodies).
  • Arrangements for delivering specialist health services.
  • Role of the National Institute for Clinical Excellence in assessing clinical and cost-effectiveness of new interventions.

Theme Three: Managing performance in the NHS

This theme flows from Theme Two, and concerns the practical issues of assessing and managing performance. Topics to be considered could include:

  • Assessment of performance – including presentation and interpretation of performance information.
  • Use of comparative performance data.
  • Clinical audit – including its use as a review process.
  • Nature of discussions about performance - confidentiality and openness.
  • Role of various organisations in assessing and managing performance – the NHS Executive (headquarters and regional offices), health authorities, GPs and Primary Care Groups.
  • Role of the Commission for Health Improvement.
  • Responsibilities of various individuals, postholders and organisations at all levels to assess and act upon performance and other information.

Theme Four: Culture of healthcare

This theme concerns the concept of "the doctor" in the NHS, and relationships between doctors, other clinicians, managers and patients:

  • The doctor-manager relationship.
  • Changing role of healthcare professionals – the clinician as manager.
  • The clinical team, including where ultimate responsibility lies.
  • Clinical freedom, including the introduction of new procedures – the role of clinical choice.
  • Referral/admissions procedures.
  • Communication with patients and carers, including communication about risks associated with procedures and the issue of informed consent.
  • Rights and expectations of patients.

Theme Five: Regulation and accountability in the NHS

This theme addresses the roles and responsibilities of individuals and organisations, the ways of spotlighting poor performance, and the ways by which better performance can be required or encouraged.

  • Self regulation – strengths, weaknesses, and alternatives.
  • Reactive and pro-active mechanisms for regulation, including complaints systems.
  • Accountability to patients.
  • Role of colleagues in raising concerns, and of the organisation in acting upon them.
  • Role of regulatory bodies.
  • Role of other organisations including the NHS Executive (headquarters and regional offices), health authorities, GPs and Primary Care Groups, Community Health Councils and other consumer and patient organisations.
  • Role of the Royal Colleges – particularly with reference to training accreditation.
  • Comparison with other professions in the UK, and with medical regulation in other countries.
  • Role and impact of litigation.

Theme Six: Education and training within the NHS

This theme addresses education and training of healthcare professionals from undergraduate courses to continuing professional development.

  • Role of medical schools, including the curriculum, and the relationship between their staff and the NHS.
  • Role of the Royal Colleges.
  • Role of regulatory bodies in setting and maintaining educational standards.
  • Continuing professional development, and links to professional accreditation.
  • Learning and the introduction of new procedures – the concept of the "learning curve".
  • Incentives created by funding mechanisms, (such as the Special Increment for Teaching (SIFT) and Research and Development (R&D) funding) for both initial training and continuing professional development.

Theme Seven: Information and information systems in health care

  • The relationship between health care information systems and quality of care.
  • NHS Information Strategy, including the National Electronic Library for Health, and electronic patient records.
  • The compilation, development and analysis of comparative data as a tool for securing better quality of care in the NHS.

Selecting Seminar Topics

  1. The proposed criteria for selection of Phase Two seminar topics are that they:
    • should be relevant and important to the development of high quality clinical services in the NHS; and
    • hold out the prospect of identifying practical recommendations achievable within a realistic level of resources.

Suggestions for possible seminar topics within the themes outlined above, and conforming to the criteria given, would be welcome.

Arrangements for the Seminars

  1. The seminars will take place in London and Bristol between January and April 2000. The practical arrangements will be announced once a final list of topics has been established, but it is envisaged that seminars will last either 1 or 2 days, depending on the subject matter to be examined. It is important to remember that most of the information put before the Panel on each theme will be in writing, and that the seminars themselves will provide an opportunity to hear in more detail from some of the contributors.


  3. The first stage of Phase Two will be for the Panel to commission papers from organisations and individuals, either on specific topics or issues or on a theme more generally. This commissioning will begin in early autumn. On receipt of those papers, the Panel will review the responses and decide from whom they would wish to hear further at a seminar, to be chaired by the Inquiry Chairman.
  1. In the second stage, the seminars will consist of short presentations from those invited to participate, followed by questions from the Panel. The seminars will be open to the public; there will be arrangements for questions from members of the public attending the seminar to be put to the seminar participants. Members of the news media will be invited to attend the seminars and will be free to report on them.

  1. The focus of Phase Two will be the future; to explore what steps are necessary to improve quality of health care in the NHS. There is no intention to discuss in public the role played by individuals involved in delivering paediatric surgical services in Bristol between 1984 and 1995.


  1. This paper has set out the proposed arrangements for Phase Two of the Inquiry. The intention is to focus on a number of broad themes, and to explore these themes through commissioned papers and a series of eight to ten seminars. The seminars will be held in public throughout the late winter and spring of 2000 and will focus on those matters relevant to the Inquiry Panel’s obligation to "make recommendations which could help to secure high quality care across the NHS".

Comments on this Paper

  1. Comments on this paper are welcome, and in particular on:

  • The themes for Phase Two.
  • Possible seminar topics within the themes identified.
  • Organisations and individuals who might be invited to contribute papers on specific questions or on a theme more generally.


Published by the Bristol Royal Infirmary Inquiry, July 2001
Crown Copyright 2001