HC Deb 18 June 1998 vol 314 cc529-39 4.47 pm
The Secretary of State for Health (Mr. Frank Dobson)

With permission, I should like to make a statement on children's heart surgery at Bristol royal infirmary.

I promised that once the General Medical Council had completed its disciplinary proceedings against the three doctors concerned, the Government would establish an independent inquiry into children's heart surgery at the infirmary. On 29 May, the GMC announced that it had concluded that many of the charges against the doctors were proved. It has taken further time to consider what action to take against the doctors concerned. Today, it has struck off two of them, Mr. Wisheart and Dr. Roylance, and censured Mr. Dhasmana. I have therefore taken the earliest possible opportunity to come to the House to announce that I have decided to set up a public inquiry into children's heart surgery at Bristol royal infirmary.

The inquiry will be established under section 84 of the National Health Service Act 1977. I hope that everyone concerned will co-operate with it. The inquiry will be chaired by Professor Ian Kennedy, professor of health law, ethics and policy at University college London. He is an eminent lawyer and expert in medical, legal and ethical issues. He has written extensively on problems arising from the care of severely disabled new-born babies. He has chaired the expert advisory group on the ethics of xenotransplantation and the advisory group on rabies and quarantine. He was a member of the expert advisory group on AIDS.

Under the National Health Service Act 1977, as chairman of the public inquiry, Professor Kennedy will have the power to require witnesses to attend the inquiry, to give evidence on oath and to produce documents. Criminal penalties are available against any who refuse to do so.

I intend to announce the other members of the inquiry and its detailed terms of reference very soon. Today I can make it clear that the inquiry will examine all aspects of what went wrong at Bristol. It will identify any professional, management and organisational failures and make recommendations to safeguard patients and their families in future.

I have had three meetings with the representatives of parents of children who died or suffered brain damage following heart surgery at Bristol royal infirmary. I was deeply impressed by their grief at what had happened to their children, by their dissatisfaction with how they—the parents—had been treated since, and by their disillusion with the clinical, professional and management arrangements which failed to deliver the standards of treatment and care that everyone has come to expect from the national health service. We owe it to them to ensure that the public inquiry gets to the bottom of what went wrong in Bristol—that all the facts are exposed and responsibility is identified. We also owe it to them to try to complete the inquiry within a reasonable period so that they can make a new start in their lives. We owe it to them and everyone else in our country to make sure that lessons are learned so that such a tragedy never occurs again.

The Government are not going to wait for the outcome of the inquiry before taking action to put in place new machinery for setting and maintaining clinical standards in the national health service. As we spelled out in December in our White Paper, "The New NHS", we are introducing a whole range of measures.

We will establish a national institute for clinical excellence to set national standards. No such organisation exists at present. We will place a duty of clinical governance on NHS trusts. They do not have such a duty at present. To make sure that the new national standards are being met, we will establish a commission for health improvement. There is no such organisation at present. We will require all hospital doctors to participate in national external audit. There is no such requirement at present.

We will enable all patients and their GPs to get information on treatment success rates at their local hospital. They have no such right at the moment. All those measures have been welcomed by the Bristol parents. They have been welcomed by the medical, nursing and midwifery professions. They will be included in our forthcoming national health service Bill. Where legally possible, we will proceed with some of the changes even before the Bill becomes law.

As I said when I met them last Friday to the representatives of the Bristol parents, the measures already in train and any further changes which result from the public inquiry will be too late to save their children; but I think I was speaking on behalf of us all when I expressed to the parents my hope that they would gain at least some small consolation from the knowledge that the lessons learned from what their children had suffered should mean that nothing like it ever happens again.

Miss Ann Widdecombe (Maidstone and The Weald)

The Opposition broadly welcome the Secretary of State's statement and the measures that he proposes to take. In particular, we welcome the speed with which he is setting up the promised independent inquiry. We also wish to extend our sympathy to the parents and relatives of all the children who died; and I can assure the Secretary of State that the Opposition will assist in any way we can in preventing such a tragedy from occurring again. I of course accept that neither he nor anyone else can give absolute guarantees.

I have some specific questions which I hope the Secretary of State will accept in the spirit of co-operation that I have just outlined. The role played by the chief executive of the hospital gives rise to concern. Recently, the Secretary of State said that under future auditing arrangements doctors will have to share their results with their senior colleagues—but who will guard the guardians? Clearly in this case such a procedure would not have worked.

The right hon. Gentleman has already announced his intention to publish mortality rates for hospitals, another measure that the Opposition have broadly welcomed. How is it intended to interpret such results, to make that interpretation comprehensible, and to make it available to the public? Transparency is essential—we welcome it—but by itself it is no use, unless it is backed up by the choice to allow patients to go elsewhere. Given the Secretary of State's arrangements for primary care groups and for the ways in which doctors will have to follow the contract patterns laid down by PCGs, how will he maintain the choice which must follow transparency?

The right hon. Gentleman will also, I am sure, accept that many agencies, not just the doctors or the hospital, were involved in this case—among them the health authority, the Department of Health, whose advice was apparently disregarded, and the Royal College of Surgeons. Will the inquiry examine the role played by each and every agency and body involved in this case; and will it then consider the appropriateness of self-regulation?

For how long is the inquiry expected to sit, and roughly when may we expect its results? Will the inquiry be able to recommend disciplinary action, if appropriate, except in the cases of those who have already been the subject of the General Medical Council inquiry?

The right hon. Gentleman rightly says that one issue thrown up by the case concerns due information being available to parents or other responsible adults, but clearly they must know not just the success rates at their local hospital but the success rates elsewhere for equivalent operations with equivalent chances of success. Will he make the giving of that sort of information absolutely mandatory for surgery of this order of magnitude?

Mr. Dobson

The chief executive in this case is one of the doctors who was subject to disciplinary proceedings, so, to some extent at least, his role as a medical practitioner has been dealt with by the GMC. His roles as chief executive and as a doctor will be the subject of investigation by the inquiry.

The right hon. Lady asked whether hospital arrangements would be adequate and whether people would, in effect, police themselves. I thought that I had made it clear in my statement that that would not happen. For the first time in the history of the NHS, we shall place a duty of clinical governance on the chief executive of every trust. Mr. Roylance did not have that duty before. We will put in place a system of national audit for all doctors' activities in every hospital, and establish a commission for health improvement which will ensure that national standards, once set, are kept. For the first time in the history of the NHS there will be people outside the hospitals checking—that is a step forward.

It is only right and proper from everyone's point of view that mortality statistics should be sensibly comparable. A system that compared mortality rates for standard operations with rates for extremely difficult, complex operations—often carried out on patients who are profoundly ill for other reasons—would be extremely foolish. That is why we have sought throughout our considerations to carry with us the people in the medical profession who are determined to raise standards.

The statistics will be available, for the very first time, to patients and GPs, who have never before had access to the figures. There will thus be greater choice and better-informed choice than ever before.

The inquiry will be able to look at every aspect of what happened in Bristol and come up with recommendations in respect of Bristol—including disciplinary proceedings if that is thought right—and in respect of ensuring more generally that such incidents never happen again.

Finally, Professor Kennedy and I would like to keep the proceedings of the inquiry as short as possible, commensurate with doing a thorough job. I hope that the lawyers involved in it will bear it in mind that one of the inquiry's objectives is to draw a line under all this so that all the families involved can start their lives over again.

Dr. Doug Naysmith (Bristol, North-West)

On behalf of the people of Bristol and the south-west, I thank my right hon. Friend and welcome his statement. I assure him that this sad, sorrowful and, in some respects, sordid affair has been of great concern to patients and parents in my constituency and other parts of Bristol. We should not forget to congratulate Steve Bolsin, one of the anaesthetists concerned, who played a great part in bringing the affair to public recognition.

Does my right hon. Friend agree that public inquiries sometimes take far too long, to the benefit of no one except, perhaps, lawyers? Will he assure me that he will try to ensure that the inquiry reports as soon as possible and that its terms of reference are drawn accordingly? Does he agree also that the Government's policies on external clinical audit, quality consultation and a commission for health improvement will ensure that such tragedies will be much less likely to occur in future?

Mr. Dobson

I welcome my hon. Friend back to the House after his illness, and I hope that he will maintain his usual rude health.

I share my hon. Friend's concern, which I have already expressed, about the possibility of the inquiry dragging on at enormous length. The chairman of the inquiry will have to exercise discipline, but there must be a great deal of self-discipline from the legal advisers of those who are represented. I repeat that we must get on with the inquiry as quickly as possible—provided, at all times, that people have the opportunity to have their say in the matter. One of the objections of the parents all along is that they have not been able to have their say.

I welcome my hon. Friend's support for our proposals for raising quality of performance in the national health service, which we have been discussing at length and in great detail with the representatives of the medical, nursing and midwifery professions. They share our hopes and aspirations that we can make sure that the arrangements in the national health service augment those in the professions, and that the professions' arrangements are considerably smartened up.

Dr. Evan Harris (Oxford, West and Abingdon)

The Liberal Democrats broadly welcome the statement and warmly welcome the announcement of the public inquiry and the choice of its chairman.

My hon. Friend the Member for North Devon (Mr. Harvey), who has been intimately involved in dealing with the families' concerns on this matter, is at the General Medical Council with his constituents and regrets that he cannot be here. He has asked me to pass on his thanks for the setting up of the inquiry.

Is there some way of ensuring that the inquiry has a smooth progress so that, at each stage, there is an end in sight for bereaved families and so that there is no doubt about whether their concerns will ever be heard? If the national audit is to be made compulsory for medical staff, will there be support in terms of resources, particularly extra staff and consultants, in the light of the British Medical Association's warning yesterday about the shortage of consultants and the stress and pressure under which medical staff work? Do the Government have any plans for specific protection for medical whistleblowers, such as the anaesthetist involved in this case, because there is still, I regret to say, a culture of fear, particularly among junior medical staff, about expressing concerns about the competence of their seniors? It would reassure many families, as well as NHS staff, if the Government could demonstrate that they are aware of that problem and will tackle it.

Mr. Dobson

I thank the hon. Gentleman for welcoming the appointment of Professor Kennedy. It has been my object since I have had contact with the parents to try to make sure that any process of inquiry satisfies them and—however hurt they may be by what has happened to their children—in the end leaves them feeling that at least they have had the opportunity to be heard and to find out what happened to their children and who was responsible.

External audit has the support of the medical profession. The hon. Gentleman jumps too quickly in asking for further resources. Doing things properly is cheaper than doing them badly. If the operations in Bristol had been a success, millions of pounds would have been saved, as well as the lives of the children concerned.

Staff should no longer be too frightened to speak out—other than those at the top who may be trying to stop people speaking out—because we have told all health authorities and trusts that they must not apply the gagging clauses on staff that were introduced when the previous Government were in power.

Dan Norris (Wansdyke)

The General Medical Council's inquiry heard that, on at least three occasions, senior civil servants in the Department of Health were informed of the tragedy that was unfolding. Despite those warnings, the then Secretary of State was not informed and the operations continued. Will my right hon. Friend reassure the House that the public inquiry, which is very much welcomed, will leave no stone unturned in finding the truth, even if that means that stones must be turned in the Department of Health?

Mr. Dobson

I thank my hon. Friend for his point, and I know that some of the parents concerned would like to thank him for his actions on their behalf. The inquiry will be failing in its duties if it does not identify shortcomings wherever they occurred, including at the highest or lowest level in the Department of Health. The inquiry is independent; it must examine all aspects of what went wrong because, if we are to prevent mistakes in future, we must identify what went wrong this time and make sure that the new arrangements will prevent it from happening again.

Mrs. Angela Browning (Tiverton and Honiton)

I welcome the Secretary of State's announcement. He will know that it will be particularly welcomed by parents in my constituency.

My question concerns the inquiry's remit, particularly with regard to whistleblowers. Because of the nature and severity of this case, the GMC has taken specific action. When the conclusions are brought before the right hon. Gentleman, will he take into account the need for a system whereby the information on staff records, particularly those of doctors at all levels—which one hopes would be made available as a result of such an inquiry—will also be made known when they apply for jobs in other hospitals and other areas?

Mr. Dobson

The hon. Lady has raised that point with me in relation to the failure of the breast cancer screening system at the Royal Devon and Exeter hospital. We hope to deal with that matter in the measures that we are introducing to improve clinical standards in the national health service. The present arrangements for checking the background of doctors who move from one hospital to another have proved to be inadequate in several cases, and that clearly needs to be sorted out.

We need to ensure that professional credit is gained by all concerned seeking to secure the highest clinical standards, so that it is clear that the ethics of the profession are to consider, first, the interests of the patients and, in all circumstances, not to allow that ethical obligation to be overwhelmed by any sense of loyalty to colleagues or concern about the reputation of the hospital. That seems to have been a problem in Bristol and other areas.

Ms Jean Corston (Bristol, East)

I welcome my right hon. Friend's statement and hope that it will bring to an end the sorry tale surrounding paediatric cardiac surgery in Bristol. Does he agree that the remit of the inquiry should include the future position of chief executives of health care trusts? One of the difficulties that many of us had was that we knew that the then chief executive was part of the same group of surgeons, who were acting in a self-protective way.

Reference has been made to whistleblowers. As long as I live, I shall never forget the look on the face of Dr. Steve Bolsin, the anaesthetist in the case, when he came to see me and the Financial Secretary to the Treasury, my hon. Friend the Member for Bristol, South (Dawn Primarolo)—who is in her place—and said, "If you were going to put a child to sleep tomorrow, how would you feel if you felt pretty certain that the child would not wake up?" He is not simply a whistleblower; he is the one person to emerge from the case with any credit. The great tragedy is that his undoubted skill and commitment have been lost to this country, because he was squeezed out of anaesthetics in the United Kingdom and has had to earn his living in Australia.

Does my right hon. Friend agree that parents sending their children for paediatric cardiac surgery at Bristol now need have no qualms, because of the excellent work of Dr. Ash Pawade and his team?

Mr. Dobson

On the principled stand of the anaesthetist to whom my hon. Friend referred, he is, as she says, one of the few people who comes out with any credit. I hope that his role and the question of how he came to be pushed out will be adequately covered by the inquiry, and that those responsible for pushing him out will be identified.

With regard to the future position of chief executives, it is our intention to place on all health trusts an obligation of clinical governance, so the chief executive will have that personal obligation. I hope that that will strengthen the position of chief executives and break any relationships with former colleagues. They will have to stand separately on clinical standards, as they do on finance. That can only benefit patients.

Mr. Ian Bruce (South Dorset)

I, too, welcome the Secretary of State's statement. The most important point for the future relates to medical and clinical audit. Will the right hon. Gentleman examine the scheme that was introduced by the previous Government but which sank without trace, and learn from the apparent mistakes in that system? He may know that for many years, on behalf of my constituent, Dr. Pull, I have been trying to get clinical audit set up. Will he look into the matter of resources? He said that more resources were not needed, but unless he grabs hold of some resources and makes sure that they are used for medical audit, that money will simply go into direct patient care. In the long term, clinical audit will save money and lives.

Mr. Dobson

It is the case that the previous Government set in train arrangements for clinical audit but, as the hon. Gentleman said, little came of that and it cost a large sum of money. There is clinical audit at present in the health service. Some of it is improving, but most of it is voluntary. It is consuming large sums, and is not well organised or comprehensive. That is why our proposals for changes in clinical governance, the establishment of the commission for health improvement and the other measures that I mentioned in my statement should improve matters, introduce better organisation and ensure that the money going into medical audit is spent to some effect, rather than being frittered away, as has happened in the past.

Mr. Tam Dalyell (Linlithgow)

As one of those who has met Professor Kennedy in another context, may I welcome the establishment of an inquiry and his headship of it? It will be important not just to Bristol, but nationally. May I, however, sound a note of caution? Let us hope that what happened in Bristol will not spill over and become a disincentive to surgeons to undertake risky operations. That is a worry of some of my distinguished surgeon constituents working in Edinburgh.

Let us be cautious about the idea that there has been great success in Scotland for the publication of hospital mortality rates. Some of us think that league tables are better suited to football than to mortality rates in hospitals.

Finally, can my right hon. Friend comment on the attendance of a member of his Department at the lecture at the Royal Society of Medicine by Lord Justice Sir Philip Otton on medical negligence? I have sent my right hon. Friend a draft of the lecture, in the hope that the issue of medical negligence will be opened up in the light of the lecture by Sir Philip Otton, who probably has more experience on the subject than anyone else in Britain.

Mr. Dobson

As ever, my hon. Friend raises a number of cogent points and identifies dilemmas that we all face. It is not intended that the publication of mortality or other performance figures should deter doctors from performing risky operations, if such operations are needed. Our intention—and our discussions with the medical profession suggest that doctors agree—is to ensure that any statistics that are published properly distinguish between the relatively simple operation on a relatively healthy patient, and the immensely complex operation on a relatively unhealthy patient. That can be done, provided that the analysis is confined to cardiac surgery. We cannot compare hip joint replacements with cardiac surgery, as some people in the consumer movement seem to suggest.

We all have doubts about publishing information about the outcomes of operations but, if the medical profession and the management of hospitals are to have the information available to them as part of the process of raising standards, it is only legitimate to allow general practitioners and patients also to have access to that information.

Mr. Dalyell

It all depends on who does the interpretation, and how it is done.

Mr. Dobson

We must remember that no patient gets access direct to a surgeon; patients' access is only through a general practitioner, who should be able to conduct the necessary interpretation. I share my hon. Friend's concern about that.

On my hon. Friend's separate point about medical negligence, I am profoundly concerned at the growing involvement of the legal profession in medical negligence matters related to the national health service. The bills keep soaring and we must act. First, we must try to reduce the number of legitimate complaints. That is one of the reasons why we are trying to raise quality. Next, we must put in place arrangements to ensure that, if something goes wrong, patients get a prompt explanation and apology and, if there has been negligence on the part of people in the national health service, patients receive legitimate compensation without having to resort to the courts. It is worth putting it on record that when people have resorted to the courts in cases of medical negligence and there is a judgment by the court, 80 per cent. of the cases are lost. In eight out of 10 cases, people were told by lawyers that they stood a good chance, but when the case came to court, it failed.

Mr. Nicholas Soames (Mid-Sussex)

I congratulate the right hon. Gentleman on the speed with which he has reacted, which I am sure will go some way to assuage the anguish of the parents of the children involved in this tragic case. I also warmly congratulate him on the steps that he has taken to ensure more effective and transparent clinical monitoring. Does he agree that it is very important that people realise that this case, although a terrible tragedy, is very much not the norm, and that the points made by the hon. Member for Linlithgow (Mr. Dalyell) need to be well taken? Does he agree that, generally, the doctors involved in such surgery in this country are absolutely brilliant and do a fantastic and remarkable job, for which we should all be very grateful?

Mr. Dobson

I agree with what the hon. Gentleman says. It is indeed the case that most people in this country, rightly, have confidence in the quality of treatment and care that they will receive in the national health service. That is of immense credit to all the people who provide that care; we want to help them improve it.

I would not wish to do anything that made people feel that they were at greater risk than they really are, but I should make a further point. In the nature of things, major operations are risky. Things do sometimes go wrong. They will always continue to go wrong. We have a duty to put in place a system that very quickly picks up when things are going wrong and does something about it. That attribute was singularly lacking in Bristol.

Mr. David Drew (Stroud)

May I, like other hon. Members, very much welcome my right hon. Friend's statement? I am sure that he is aware that the impact of the tragedy goes well beyond the immediate Bristol area, and affects the whole of the south-west. One of the criticisms voiced about the GMC inquiry was that the parents who were able to give evidence came from a fairly selective group. Will he ensure that parents who have perhaps been unable to give evidence get the opportunity to talk to the inquiry?

Mr. Dobson

Yes, I certainly shall. Having talked to representatives of the parents three times, I know that they are greatly concerned to ensure that all those parents who wish to have a say, have a say, and in some cases to find out in considerable detail what happened to their child. But there are other parents who positively do not want to go into the detail of what happened to their child. We must try to ensure that, at the end of the inquiry, all the parents feel that they have had a fair say, and that the inquiry has got to the truth. If we can do so, it will be a very useful achievement, and I hope that it will bring some comfort to the parents.

Dr. Tony Wright (Cannock Chase)

I congratulate my right hon. Friend on his statement. However, as a parent of a child who died of cardiac surgery during the time of the Bristol cases—although, fortunately, not in Bristol—and who tried at the time to get performance data on the centre where the operation was performed and failed, and indeed was refused; and who subsequently in the House has tried to get general performance data on the national health service in general and failed, may I say to my right hon. Friend that the Bristol case, although appalling, has wider lessons for the national health service?

Does my right hon. Friend accept that there has been a conspiracy of silence, involving both the professionals and the politicians, on the issue of clinical performance? Will he therefore ensure that the terms of the inquiry that he announced today are broad enough to deal with that issue? Finally, as an immediate response to the Bristol case, will he today put in place provision to ensure that the performance data for all the centres performing paediatric cardiac surgery are now made available to parents?

Mr. Dobson

As my hon. Friend knows, I have been aware of his family circumstances, and I know the efforts that he has been making in this matter. To some extent there has been a conspiracy of silence. I believe that, in many cases, it has been an unconscious conspiracy of silence, in that people have felt, "We never gave the figures in the past; why should we give them now?" However, in fairness to the medical profession—certainly since we came to power—my ministerial colleagues and I would say that the profession has never been as committed as it now is to raising performance standards, recognising that targets will have to be set and agreeing to put in place arrangements to ensure that those targets are met.

In the end, we must depend on the surgeons to set the standards. It is no good asking anyone else, "What is the best way to do a liver transplant?" The only person one can get the standard from is the person who does liver transplants. Having set the standard, though, they must maintain those standards; that is the important point.

I cannot agree casually, at the Dispatch Box, to release figures for children's heart operations throughout the country, partly for the reasons that my hon. Friend the Member for Linlithgow (Mr. Dalyell) gave. If the material has not been prepared in a form that is properly comparable, it could be extremely misleading. I want to ensure that the information is put together in a properly comparable way and made available, but I must take great care to ensure that the idea of assembling and publishing that information is not brought into disrepute by publishing misleading figures early in the process.

Mr. Paul Flynn (Newport, West)

I thank my right hon. Friend on behalf of the many families in south Wales, including my constituency, who were bereaved in this dreadful way. The worst part of their torment is the belief that their child's life may have been sacrificed to improve the skills of surgeons who were semi-competent and never became competent.

The right hon. Member for Maidstone and The Weald (Miss Widdecombe) asks who will guard the guardians. The sad fact is that we do not even have guardians in our health service now. For many years many hon. Members, including my hon. Friend the Member for Cannock Chase (Dr. Wright), have been asking for systems of audit, of examination, and of transparency, similar to those that are available in Scandinavian countries, to be set up in our health service.

I ask my right hon. Friend to consider the fact that, throughout the health service, we have that information. We have information on, for example, the number of drugs used and the dreadful over-prescription of drugs among elderly people. I urge him to channel all his energies in that direction and not to be distracted by some of the other superficial measures of the efficiency of the health service, because it is in transparency that the greater reforms will take place.

Mr. Dobson

I think 1 can safely say to my hon. Friend that my ministerial team and I have devoted a huge amount of effort, thought and time to consulting the professions on how best to assemble accurate and useful data which will lead to raised standards of performance in the health service, and which will be meaningful, and not misleading, to members of the public—and to general practitioners. We have put a great deal of effort into that, and we intend to continue to do so. Generally speaking, the statistical system within the Department of Health is deplorable; that is one reason why we need to take great care in publishing almost any information that it has, because it could be very, very misleading.

Mr. Robert McCartney (North Down)

I join other hon. Members in congratulating the Secretary of State on the measures that the Government have undertaken to take to deal with this very important problem. As someone who, for more than 30 years, has practised in medical negligence cases, I endorse his observation that some 80 per cent. of legal medical negligence cases fail. However, those who grant legal aid in many such cases are under a duty merely to determine whether the evidence shows not a case that is bound to win, but a prima facie case. Many members of the legal profession sometimes encourage litigation when it is not altogether justified.

In relation to the issue of league tables, it is very important that we compare like with like. Not simply cardiovascular surgery but other operations within that specific discipline vary greatly in the degree of expertise that is necessary to ensure success. One could easily find that the centres of absolute excellence are engaged in the most high-risk surgery and are at the frontier of surgical progress. One would hesitate to engage in any measures that brought about the practice of defensive medicine or defensive surgery. That point must be kept carefully in view.

Mr. Dobson

I welcome the views of any lawyer who is willing to accept that, the more we can manage to keep lawyers out of the health service, the better. There are several hospitals in my constituency, including Great Ormond Street hospital for sick children. For many sick children, it is the hospital of last resort. The surgeons at that hospital sometimes operate on children who have had two or three operations at one or more other hospitals and they frequently do not succeed in preserving the health or saving the lives of the children concerned. Therefore, I have always been acutely aware of the necessity, when looking at any production or publication of figures, of ensuring that the complexity of operations and the state of the patients are reflected properly.

The president of the Royal College of Surgeons and the immediate past president support our proposals. I believe that we are proceeding fairly quickly and making substantial efforts to carry with us the people who, in the end, must do the operations. The last thing I want is for surgeons in the operating theatre to be thinking, "What will the lawyers or the jury think?" They should be thinking only, "What is best for the patient, here and now?"