Bristol Inquiry: key questions

The Bristol Inquiry report into baby heart deaths at Bristol Royal Infirmary confirms that, in the late 1980s and early 1990s, the performance of the local children’s heart surgery unit did not improve as rapidly as that of comparable units in other hospitals.

It indicates that a range of individual and system failures were responsible for this differential, which it estimates caused between 30 and 35 deaths in the Bristol unit between 1991 and 1995 that might not have occurred in other units.

But the key point is that the Bristol Inquiry was more the result of the drive for reform of the medical profession, than it was the cause of it. The UK General Medical Council (GMC) and the government have seized on the Bristol case to make an example of the doctors involved and to whip up public support for a new system of regulation of the medical profession.

• The reformers: Donald Irvine, Ian Kennedy, Alan Milburn

By personally chairing the long-running GMC inquiry into Bristol in 1998, its president Donald Irvine ensured that the case received a high media profile. The personal animosity he seemed to display towards the three doctors who were subsequently struck off the medical register helped to stir up the public mood. In this way, Irvine provided renewed impetus to the drive to introduce the new systems of revalidation and reappraisal for doctors that he had been promoting for nearly two decades.

In his Reith lectures of 1980, Professor Ian Kennedy demanded that ‘a wholly new system of supervision and sanction must be created’ for doctors. His diatribe against the medical profession was published in 1981 with the title The Unmasking of Medicine. His 20-year campaign culminated in his appointment to the Bristol Inquiry, signalling that the government had now decided to support the drive for closer state control over medical practice.

Health secretary Alan Milburn, in endorsing the drift of the Bristol Inquiry report in his statement to parliament on 18 July 2001, confirmed that the government planned to take advantage of the Bristol case to push ahead with the introduction of a comprehensive framework of bureaucratic regulation of medical practice.

The major victims of this process have been the Bristol parents, whose grief has been exploited and manipulated by this political clique, in pursuit of an agenda of reform that has gradually taken shape over the past two decades.

• Club culture or whistleblowers’ culture?

If the villain of the Bristol report is the ‘club culture’ prevailing among senior doctors, the hero is the whistleblower who first leaked reports of the unit’s failure to the press.

Yet it is not surprising that doctors, who work long hours together in difficult conditions, develop a certain camaraderie. Indeed, the spirit of trust and cooperation required for the teamwork of modern medical practice would be impossible without the development of a culture of collective commitment and solidarity.

Though it may be true that this spirit, now disparaged as ‘club culture’, occasionally shields incompetence or worse, the cost of its destruction would be even higher than that resulting from cases such as Bristol.

The culture of the whistleblower encourages doctors to spy on one another and to inform higher authorities, rather than try to deal with problems through informal mechanisms. In general practice, locums who cover for colleagues on holiday or study leave are already being advised to report on any deviations from approved standards of practice.

The corrosion of trust and mutual sympathy that is likely to result can only demoralise doctors and damage clinical practice. The medical profession should be warned that the model for this climate of ‘iron discipline and organised distrust’ is the Soviet regime under Joseph Stalin.

• The spiral of distrust

The trend of the reforms currently being introduced – and now receiving added impetus from the Bristol report – is to replace trust in the doctor with trust in some third party. This means new systems of regulation, which establish and enforce standards of practice; and new methods of revalidation, which provide regular appraisals of doctors’ fitness to practice.

The problem here is that if the public loses trust in doctors, why should they trust the regulators or any system of regulation? (The fact that any such system of regulation is likely to be run by doctors who, for one reason or another, have decided to give up front-line practice, is not likely to enhance confidence in this process, either among doctors or the public).

As Professor Michael Power writes in his powerful critique of The Audit Society – a trend he has identified as spreading from the financial sector into all areas of society – attempts to put trust in third parties create a ‘spiral of mistrust’, spreading inefficiency and cynicism through organisations, as they work to fulfil artificial targets and meet imposed standards instead of getting on with the job.

• ‘Informed consent’ or passing the buck?

In the cause of slaying the demon of ‘paternalism’, the Bristol report seeks to replace the subtleties of the doctor-patient relationship with the imperative of ‘informed consent’ – the necessity for openness and transparency in all interactions between doctors and patients.

One result of the introduction of this approach is that, as a GP, I am regularly consulted by patients who have seen a consultant and have been provided with so much information that they do not know what to make of it. As one man said to me, ‘I thought he was supposed to be the expert, but he seemed to expect me to decide whether the operation was necessary or not’. Patients feel that the burden of responsibility for clinical decisions has been transferred from the doctor back to them.

The problem is that, when it comes to submitting to the surgeon’s knife, no statistics on outcomes, no league tables, no amount of information and advice can overcome the gap of knowledge, expertise and experience between doctor and patient. When it comes to the leap of faith required, trust is what counts – and trust is more likely to be undermined than strengthened by the new cult of openness, which may well amount to an evasion of responsibility by doctors rather than a genuine sharing of information.

• Arrogance?

The popularity of the current reforms among doctors indicates that the real problem is not so much medical arrogance as the paralysing diffidence that now afflicts the medical profession. Doctors appear to have lost their nerve and their confidence in defending those elements of their professional traditions that are essential to good medical practice.

Dr Michael Fitzpatrick is the author of MMR and Autism, Routledge, 2004 (buy this book from Amazon (UK) or Amazon (USA)); and The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA). He is also a contributor to Alternative Medicine: Should We Swallow It? Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)).

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