How can we watch the doctors?

FRIDAY'S verdict by the General Medical Council on the three doctors involved in the Bristol heart surgery case will mark a watershed in the way medical practice is regulated in Britain.

The case, which began last October, is the longest in the GMC's history and has already had widespread repercussions. It has exposed a central weakness in the NHS - the absence of clear standards against which doctors' performances can be measured.

To patients it seems extraordinary that there are no measures for judging whether a doctor is good at the job. Medical organisations have previously argued that clinical practice is too complex, and patients too varied, for measures to be meaningful. That view is now history.

The case centred on 53 babies and children who were born with congenital heart defects and were operated on by the two surgeons, James Wisheart and Janardan Dhasmana, at Bristol Royal Infirmary between 1988 and 1995. A total of 29 babies died and four suffered brain damage. The GMC concluded that the evidence was strong enough to show that six of the operations, three by each surgeon, should not have gone ahead. Five of the six operations ended with the death of the child. A third doctor, John Roylance, chief executive of the infirmary at the time, should have prevented the operations going ahead but failed to do so, the GMC found.

The hearing, which has been adjourned until mid-June, will next consider whether the charges proved amount to serious professional misconduct and whether the doctors should be struck off the medical register.

All three deny misconduct. If found guilty, they are expected to appeal.

The most extraordinary feature of the case is the way the doctors ignored repeated warnings about their high death rates. Over a period of six years from 1988 to 1994 concerns were raised by anaesthetists in the department, by the Royal College of Surgeons, by the professor of adult cardiac surgery at Bristol, Gianni Angelini, and eventually by the Department of Health itself.

An investigation by the BBC1 Panorama programme, to be shown tomorrow, names a health department under-secretary, Dr Norman Halliday, who had responsibility for overseeing Bristol and the other specialist children's units and who knew of the problems there in 1992, three years before official action was taken to investigate it.

The programme also discloses that a 1989 report commissioned by the health department showed that Bristol had the highest number of deaths of the nine national children's heart units - and that concerns had been raised about its performance by other specialists since the mid-1980s.

Sir Terence English, former president of the Royal College of Surgeons, tells the programme that the delay in taking action was "obviously very regrettable", but blame could not be laid at the door of the college.

Part of the reason why the warning signals were ignored was that there were no clear standards by which to judge when a poor level of performance became unacceptable. This has set alarm bells ringing among medical organisations and catalysed them into action.

Many surgeons watching the events unfolding at the council's headquarters in London over the past seven months have been relieved that they have escaped the same fate. Last December, two months after the Bristol case had begun, the Society of Cardiothoracic Surgeons called an extraordinary general meeting because of growing concern at the number of heart surgeons facing allegations of incompetence.

It disclosed that 18 out of the 199 consultant cardiac surgeons in Britain, almost one in 10, had been investigated after questions about their safety record had been raised by colleagues or hospital managers.

The society is now to collect data on individual surgeons' death rates so that it can intervene early to protect patients.

Cardiac surgeons lead the field in their efforts to monitor performance, because theirs is a high-profile speciality where the outcome is easy to measure: literally, life or death.

Other specialities have lagged behind. This month the British Medical Association and the royal medical colleges branded the efforts by doctors to measure their performance, which stretch back 20 years, a failure.

In a report on self-regulation, it said: "Too often doctors are given no adequate markers against which they can audit their work. To remedy this deficiency, a new drive to set standards is now under way with pressure coming from the Government, the GMC and professional medical bodies. The Academy of Royal Medical Colleges has asked all hospital specialities to supply outcome measures against which the performance of individual doctors can be assessed.

For some specialities, suchas heart surgery, the measure used may be death rates while others, such as hip replacement surgery, the measure could be revision rates (the proportion of operations that need repeating within a certain period).

To clarify standards of conduct expected of doctors, the GMC this month issued a new edition of its guide, Good Medical Practice, spelling out the requirements on doctors to provide comfort and care as well knowledge and skill to patients.

Sir Donald Irvine, the chairman of the GMC, said a "revolution" was under way with all medical organisations seeking to introduce standards.

Ministers will contribute to the new drive for quality with the announcement , expected soon, of how their own plans for improving clinical performance through the Commission for Health Improvement and the National Institute of Clinical Excellence, heralded in last November's NHS white paper, will work.

Malcolm Curnow, co-ordinator of the parents group, whose own child Verity died following heart surgery at the Bristol Royal Infirmary, said after Friday's verdict that nothing could bring the dead children back, but some good could come out of their deaths. "Something has to be done about the regulation of doctors," he said. There is now growing pressure from all sides to see that there is.