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Hearing summary

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 RCN’s 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 children’s 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,
   1     so perhaps I could start by asking Mrs Jenkins, please,
   2     to stand whilst she affirms.
   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?
   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
   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?
   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
   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
   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?
   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?
   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
   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
   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:
   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
   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
   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
   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
   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
   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
   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
   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
   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
   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
   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
   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.
   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
   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
   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?
   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.
   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
   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.
   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
   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
   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.
   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
   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
   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
   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
   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
   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
   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,
   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
   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
   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
   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
   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
   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
   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
   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
   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
   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.
   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
   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
   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
   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
   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
   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
   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
   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
   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,
   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
   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
   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
   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
   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
   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
   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
   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
   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
   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
   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.
   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
   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
   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
   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
   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
   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.
   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.
   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
   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
   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.
   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
   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
   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
   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?
   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
   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
   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
   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.
   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
   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
   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
   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
   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
   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
   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.
   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
   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
   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,
   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
   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
   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
   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
   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 --
   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
   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
   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.
   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
   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
   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
   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
   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
   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
   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
   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
   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,
   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
   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
   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
   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
   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,
   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
   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.
   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
   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,
   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
   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
   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 œ5, 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.
   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
   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
   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
   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
   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
   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.
   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
   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
   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.
   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.
  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
   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,
   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
   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.
   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.
   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.
   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
   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
   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
   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?
   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.
   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
   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,
   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)
   1                I N D E X
   3     MRS LIZ JENKINS (Affirmed)
   4     and
   5     MISS SUE BURR (Affirmed)
   6        Examined by MISS GREY ........................ 2
   7        Examined by THE PANEL ........................ 121
   9     APPLICATION BY MR LISSACK ......................... 136
  10     RESPONSE BY MISS AUSTIN ........................... 142
  11     REPLY BY MR LANGSTAFF ............................. 143

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