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2 April 1999

Bristol won’t happen again – will it?

Quality control and more money: just what Dr Phil Hammondorders for the NHS

By Dr Phil Hammond

On 16 March the largest ever public investigation of clinical practice in the NHS began hearing evidence. The inquiry, chaired by the law professor Ian Kennedy, will look at all paediatric cardiac surgery done in one specialist centre between 1984 and 1995. The process will be tortuous and will drag on into the next millennium, but Kennedy’s goal sounds simple enough: to uncover the truth about what happened and to ensure that there is “never another Bristol”.

Last year, the General Medical Council reached a limited vision of the truth after its own largest ever inquiry. It restricted its examination to two surgeons (James Wisheart and Janardan Dhasmana), a doctor-turned-chief executive (John Roylance) and 53 children and babies, 29 of whom died and four of whom were left brain-damaged after surgery. Contrary to most press coverage, the GMC did not rule that either surgeon was technically incompetent but judged that they had “continued to perform certain operations despite growing concerns about poor mortality figures. They did not adequately establish the causes of those results. One of them [James Wisheart] misled parents about likely outcomes. And the then chief executive failed to take action when colleagues voiced anxieties . . .”

The GMC found all three men guilty of serious professional misconduct, struck off two and barred the third from operating on children.

In the public mind, the blame was crystallised around these three but it is likely that Kennedy’s examination, which covers over 2,000 operations, will expose systematic failures at all levels from the operating theatre to Whitehall. As far back as 1988, an audit carried out for the Department of Health and Social Security found that the Bristol Royal Infirmary had significantly worse results than any other paediatric centre in the United Kingdom. The response then was not to launch an investigation, but to increase the funding to the unit. Can a government be allowed to pour money into a public service without taking any responsibility for the outcome?

Evidently, yes. At the GMC inquiry, the DoH audit supremo, Dr Peter Doyle, voiced doubts that even the former health secretary Virginia Bottomley could have stepped in to stop the operations. She took up her post after the April 1992 election, a month before I first wrote about the problems of heart surgery in Bristol in Private Eye.

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In three subsequent articles, I specifically brought the poor results to the attention of Bottomley, the constituency MP, William Waldegrave, the NHS Executive, the Royal College of Surgeons, the trust board and the health authority. The detail was such that it could only have come from whistle-blowers inside the unit. Yet the operations continued for another three years.

To be fair, the Royal College of Surgeons did try to take action in 1992 when Sir Terence English informed the Department of Health that he considered that the Bristol Royal Infirmary should lose its designated status as a specialist centre for child heart surgery. Nothing came of this attempt. The GMC, too, was at least made aware of the Private Eye articles by the ex-GP Michael O’Donnell, who mentioned them at a council meeting but was told, “don’t worry – Wisheart’s a good chap”. O’Donnell knows the workings of the GMC better than anyone, having served on the council for 25 years. His synopsis is telling: “There may have been many other cases like Bristol but this was unique in that someone [an anaesthetist, Steve Bolsin] had gathered the evidence.”

Bolsin, too, is unsure that “a Bristol” is not happening at this very moment. Until recently, quality control in the NHS remained largely voluntary. Even when a doctor’s performance is clearly unacceptable, the culture of self- protection and professional loyalty is a hard one to change. Those who work in a hospital know who they’d send their mother to and who they wouldn’t send their dog to, but there’s no way they would let out this sort of information. In Bristol, some of the staff became so desensitised by the high death rates they were witnessing that they dubbed the unit “the killing fields” and “the departure lounge”. But they didn’t dare warn the parents or make their concerns public.

There has at least been the start of a culture shift in doctors’ attitudes since Bristol. The Royal College of Surgeons has set up a rapid response force and the GMC has produced mandatory ethical codes of conduct for doctors. These include a duty to monitor our own fitness to practise and to act swiftly if we think a colleague may be putting others at risk. The GMC president, Donald Irvine, has promised regular re-examination of doctors and the council now has more lay members than ever before. Despite these fine words, the GMC still hasn’t got much of a clue what’s happening “out there”.

The solution – according to both the GMC and the government – is clinical governance, a system of accountability that devolves responsibility for self-regulation to individual hospital teams and GP practices. This, too, looks good on paper, though it remains to be seen if it will be given the resources to make it work. Audits are costly and take up time that could be spent seeing patients or meeting government waiting-list targets.

Ultimately, it’s a rationing decision. Do we want the cheap NHS we’ve had for 50 years where the doctors are all jolly good chaps doing their best in difficult circumstances and mistakes are buried with the patients? Or do we want to pay a lot of money to find out just how good (or patchy) the service really is when we may not have the money to make it better?

There are also big problems in the way we train doctors. Undergraduate education has been lamentably poor for years, producing house-officers who have few of the skills they need to practise safely. In the first few months after qualifying, new doctors face the steepest learning curve of their lives and are heavily reliant on the nursing staff to train them. In 1997, a survey of junior surgeons found that many were left unsupervised to perform highly complex operations for the first time.

Medical training has for years relied on stretching doctors beyond their competence and, as a consequence, every doctor I know can tell horror stories about harming patients.

There are surprisingly few definitions of minimal competence for what doctors do and hence very little scope for ensuring these standards have been met. As one surgeon put it: “If we all had to prove our competence before performing an operation, the NHS would collapse overnight.” So we muddle through and hope no one spots our mistakes. And when poor results happen, it’s hard to distinguish between the faults of the staff and failures of the system. At Bristol, the operating theatre and intensive care unit were on separate sites, there was often a shortage of beds and trained staff, and the unit did not have a specialist paediatric cardiac surgeon. It probably should not have done complex child heart surgery at all, but if the Department of Health was happy to fund the service and there was no minimal standard that had to be attained, why stop?

Surgeons can’t operate if patients aren’t referred to them and there is evidence that some babies were bypassed around Bristol to Southampton and London because cardiologists were not happy with the standard of the service provided there. This prompts the question, why did other cardiologists continue to refer to Bristol? Part of this may have been to support the local unit but both GPs and cardiologists have spoken off the record about the political pressure they have felt to refer locally.

Freedom of choice has always been a mirage in the NHS, and the competitive Tory health reforms encouraged all hospitals to operate in-house when a better option might have been to refer elsewhere.

It isn’t hard to find examples of preventable loss of life in the NHS that has happened over many years. On Trust Me, I’m a Doctor (BBC2, 26 February), we ran a story about babies with biliary atresia, a rare liver disease that causes death within a year if untreated. The treatment – called a Kasai operation – was first audited in 1985. This showed that specialist liver centres that carried out more than five operations a year and had the necessary support team got far better results than non-specialist centres averaging one or fewer operations per year. But recommendations that all operations be done in specialist centres were ignored, and a repeat audit ten years later found the same thing. Babies were dying and suffering unnecessary liver transplants because they weren’t getting good treatment the first time round.

This last audit was completed in 1996 but remained unpublished until a consultant contacted me in August 1998. I then wrote to the GMC (I still haven’t had a reply) and published the audit in Private Eye. I then contacted the Children’s Liver Disease Foundation, which for years has been trying to get the operation designated to specialist centres. But the Royal College of Surgeons and other professional bodies have opposed the move and the Department of Health has been “unable” to overrule them. However, as soon as it became clear that the BBC was running the story and the CLDF was officially releasing the audit figures, the Royal College of Surgeons did a U-turn in 24 hours and backed the designation of the operation to specialist units. But this rapid response came much too late for some babies.

In four series of Trust Me, we’ve uncovered many examples of patchy quality care, from cancer surgery to amniocentesis. The advice from doctors is consistent. Blind reliance on medical self-regulation doesn’t work, so you have to do it yourself. Ask doctors how many operations and procedures they do, what their results are, and how they compare to the national average. But as well as asking searching questions, we need to finance improvements in medical training. We get the NHS we pay for and the doctors we deserve.

Phil Hammond is a GP and presenter and author of “Trust Me, I’m a Doctor” (published by Metro Books at £9.99. Telephone sales 0500 418419)