Leading Article: Can our doctors be left to look after themselves?

FOR MOST of the next month, celebrations of the 50th anniversary of the National Health Service will be an ever-present theme across politics and the media. Most of the coverage will, perfectly sensibly, ponder the structure of the service - how best to fund it, whether it needs fundamental change and how efficiently it meets the demands we place on it. But beneath these questions lies a more fundamental question about the medical profession. Are doctors themselves living up to the role we expect of them?

The organisation of the medical profession is still essentially unchanged from that of a century ago, with the training and licensing of doctors and surgeons in the hands of Royal Colleges that date back to the16th century. The main difference is that today doctors are, for all that cases such as the Bristol Royal Infirmary expose a deep-seated complacency that protects malpractice, amongst the best paid and most trusted professionals. Until just over a century ago, however, they were neither well rewarded nor well regarded. In the 19th century physicians, surgeons and the despised apothecaries plied their trades as equals in law. In 1858 Parliament created a single register and a single council to co-ordinate medical education. Since then, the growth in the power and influence of doctors has been unrelenting.

This has been due, in part, to the Royal Colleges' deliberate strategy of imposing strict limits on the numbers allowed to qualify, and ensuring that the serf-like apprentice existence of junior doctors lasts many years - a tactic that remains a central cause of the Royal College's power to run the show. Whether it can last, however, is doubtful - when it is common for British doctors to train and qualify abroad, and in an age when professional barriers are constantly under question. Only yesterday Dr Richard Kaul, an anaesthetist who qualified and acts as a consultant in the United States but has been told he must undergo further training to practise in the UK, announced that he is to sue the Specialist Training Authority, which operates on behalf of the Royal Colleges.

The issue of qualification is, of course, important on its own. But it is also representative of a more general malaise in the medical profession - the club-like, closed mentality of secrecy that regards any change as a step backwards and thinks of outsiders as troublemakers to be kept at bay. Like any club, the medical profession tends to be self-replicating. Three-quarters of applicants to medical school have professional parents and nearly one in five has a doctor parent. Worse still, when the Commission for Racial Equality examined appointments to consultant jobs, it found that out of 147 vacancies, 53 per cent of applicants, but only 27 per cent of the appointments, were from ethnic minorities. It concluded that "the disparities in success rates ... were so marked and consistent, and the omission of procedural safeguards so routine, that the possibility of discrimination cannot be ignored".

The Bristol Royal Infirmary tragedies were due to the culpability of individual doctors. But as the General Medical Council now appears to recognise, this "us against the world" outlook works against any possibility of bringing malpractice to light. In an attempt to inculcate a greater sense of duty towards the protection of high standards, rather than the protection of colleagues, the GMC is now to distribute 200,000 copies of a new handbook setting out doctors' responsibilities and telling them when they should report colleagues to protect patients from bad practice.

The positive side of self-regulation and clubability is supposed to be a shared commitment to excellence, although that theory has taken a blow in recent weeks. It is just possible that the outcry over the cover-up in Bristol will have positive repercussions. But the speed of progress in the medical profession is notoriously slow, and the likelihood is that, for all the GMC's apparent effort, we will not have to wait long for the next avoidable disaster.