BMJ 1998;316:1917-1918 ( 27 June )

Editorials

All changed, changed utterly

British medicine will be transformed by the Bristol case

News p 1924Letters p 1986

"The Bristol case," in which judgment was passed last week1 will probably prove much more important to the future of health care in Britain than the reforms suggested in the white papers. Reorganisations of the NHS come round with monotonous regularity, but changes on the wards and in surgeries are slow and often unrelated to the passing political rhetoric. 2 3 In contrast, the Bristol case is a once in a lifetime drama that has held the attention of doctors and patients in a way that a white paper can never hope to match. The case has thrown up a long list of important issues (see box) that British medicine will take years to address. At the heart of the tragedy, which has been Shakespearean in its scale and structure, is, as the GMC said, "the trust that patients place in their doctors." That trust will never be the same again, but that will be a good thing if we move to an active rather than a passive trust, where doctors share uncertainty.

The trust between doctors and patients works on two main levels: between individual patients and doctors and between society and doctors' organisations. The Bristol case will affect both. The most profound---but least easily measured---effect may well be on the relationship between individual doctors and patients. In the past two weeks the case must have been in the minds of many patients consulting doctors, particularly those about to undergo operations. Worldwide, the doctor-patient relationship is changing.4-6 For instance, the main theme of last week's world conference of general practitioners in Dublin was the change from patients being passive recipients of care to being active partners in all decisions; it was also the theme of the first conference to celebrate the 50th anniversary of the NHS. Evidence is growing that as patients become equal partners in the doctor-patient relationship then outcomes and satisfaction improve and costs fall. 4 7 If the Bristol case hastens the move to patients being treated as equals it will have produced real benefit.

The Bristol case has already accelerated the move to provide patients with data on the performance of doctors and hospitals,8-10 and this has to be a good outcome. Cardiothoracic surgeons have already taken impressive steps,10 but they are way ahead of the pack. Doctors in other specialties, particularly non-surgical ones, are going to have to think hard and fast about how to gather and present data on their performance.11 Neither gathering nor interpreting the data is easy,12 and experts on improvement emphasise that such data are best used as a source of knowledge for improvement rather than for judgment. 13 14 If the Bristol case leads to an environment where we concentrate on removing bad apples rather than improving the whole system then both patients and doctors will suffer. There must be mechanisms for responding to doctors whose performance has deteriorated to an unacceptable level, but such mechanisms will never bring about the systemic improvements that we need.

Issues raised by the Bristol case
The GMC identified several issues that arose during the course of its inquiry that concern the practice of medicine and surgery generally and that need to be addressed by the medical professsion.

  • The need for clearly understood clinical standards
  • How clinical competence and technical expertise are assessed and evaluated
  • Who carries the responsibility in team based care
  • The training of doctors in advanced procedures
  • How to approach the so called learning curve of doctors undertaking established procedures
  • The reliability and validity of the data used to monitor doctors' personal performance
  • The use of medical and clinical audit
  • The appreciation of the importance of factors, other than purely clinical ones, that can affect clinical judgment, performance, and outcome
  • The responsibility of a consultant to take appropriate actions in responses to concerns about his or her performance
  • The factors which seem to discourage openness and frankness about doctors' personal performance
  • How doctors explain risks to patients
  • The ways in which people concerned about patients' safety can make their concerns known
  • The need for doctors to take prompt action at an early stage when a colleague is in difficulty, in order to offer the best chance of avoiding damage to patients and the colleague and of putting things right

Although dramas like the Bristol case are powerful levers for change, they tend to lead to key protagonists overreacting. Frank Dobson, the secretary of state for health, made a serious mistake last week when he announced on television that all three of the doctors in the Bristol case should have been struck off (only two were1). He has met several times with parents of the Bristol children, and it is understandable that he has been affected by their grief and outrage. Less understandably, he may also have been influenced by Labour spin doctors' interpretation of public opinion. Even the strongest supporters of the Labour government bemoan its excessive concern with media opinion. Mr Dobson cannot possibly have read the evidence produced over more than 60 days at the GMC, and in a calmer moment he surely would not advocate judgment by public opinion rather than a judicial process that operates under act of parliament.

Mr Dobson will inevitably confer with his spin doctors and consider whether the time has come to end self regulation for doctors. The GMC, the keystone of self regulation, has long been criticised, 15 16 and the whole notion of self regulation---not least for members of parliament---is suspect in this age of increased accountability. My judgment is that the government will decide against wholesale reform of the GMC. Firstly, although previous presidents may have been slow to read the signs that self regulation was under threat, the current president, Sir Donald Irvine, has committed himself to substantial reform. 17 18 Secondly, the government won't want to waste its time fighting with doctors while trying to modernise the NHS: the rhetoric is all about partnership. Thirdly, the Treasury will not want to pick up the cost of trying errant doctors. Fourthly, a system run by non-doctors would inevitably depend on doctors for judgments on what was acceptable, and doctors (clever people still) would probably prove adept at subverting a system that they didn't own. Fifthly, the government will want to try out the many systems it has proposed in its white paper for raising performance.

Moreover, reforming the GMC misses the point: regulation of doctors is not all about the GMC. Innumerable groups influence the practice of doctors, and some of them, I have argued elsewhere, have much more influence than the GMC.3 The council may control the ultimate sanction of removing a doctor's licence to practise, but its influence is not felt every day: to the average doctor it feels distant. In contrast, teachers and colleagues have both power and everyday influence. Royal colleges and postgraduate deans also have great influence, and they must recognise their role in self regulation. It is this local, everyday self regulation that has been especially weak, but there are now signs that it is being taken seriously.19 The challenge is to maintain the impetus for improvement created by the Bristol case and turn fine words into effective actions.

The consequence for the British medical profession of failing to act effectively could be serious. The BMJ and other journals publish many studies showing that doctors fail to practise in line with the best evidence and continue to provide poor service: just last week the BMJ published the results of a confidential inquiry showing poor care of many patients before admission to intensive care units.20 The government has proposed in its white paper the concept of clinical governance, which means that trust boards will be responsible not only for financial and legal affairs but also for ensuring a high standard of clinical care. It remains ambivalent over how much clinical governance is management of or management by clinicians. Failure of doctors' organisations to implement much better mechanisms for ensuring high quality of care may lead to the micromanagement of doctors that is routine in the United States.

Richard Smith, Editor. 

BMJ

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  4. Coulter A. Partnerships with patients: the pros and cons of shared clinical decision-making. J Health Ser Res Policy 1997; 2: 112-121.
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  9. Warden J. Hospital death rates to be published for England. BMJ 1998; 316: 1767.
  10. Keogh BE, Dussek J, Watson D, Magee P, Wheatley D. Public confidence and cardiac surgical outcome. BMJ 1998; 316: 1759-1760[Full Text].
  11. Johnson JN. Making self regulation credible. BMJ 1998; 316: 1847-1848[Full Text].
  12. McKee M. Indicators of clinical performance. BMJ 1997; 315: 142[Full Text].
  13. Berwick D. Primer on leading improvement of systems. BMJ 1996; 312: 619[Full Text].
  14. Berwick D. The NHS: feeling well and thriving at 75. BMJ (in press).
  15. Stacey M. Regulating British medicine: the General Medical Council. Chichester: Wiley , 1992.
  16. Smith R. Profile of the GMC. The day of judgment comes closer. BMJ 1989; 298: 1241-1244[Medline].
  17. Irvine D. The performance of doctors. I: Professionalism and self regulation in a changing world. BMJ 1997; 314: 1540-1541[Full Text].
  18. Irvine D. The performance of doctors. II: Maintaining good practice, protecting patients from poor performance. BMJ 1997; 314: 1613-1614[Full Text].
  19. BMA, Academy of Medical Royal Colleges, COPMED, Committee of Undergraduate Deans. Making self regulation work at a local level. London: BMA , 1998.
  20. McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, et al. Confidential inquiry into quality of care before admission to intensive care. BMJ 1998; 316: 1853-1858[Abstract/Full Text].

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