Tragic case that proves need for

The Bristol three case shows that the GMC cannot put institutions on trial,

writes Rudolf Klein, Professor of

Social Policy at the University of Bath

THE verdict of the General Medical Council in the case of the Bristol three is bound leave a sense of perplexity. Here was a case that started on a high tide of emotion involving as it did the apparently unnecessary death of small babies; deaths which as the evidence given during the trial confirmed, might have been prevented if they had been operated on by other surgeons working at a hospital with a better record. But it has ended in a complex judgement, many of the charges brought against doctors concerned have been dismissed. Tragedy has ended in confusion.

Inevitably, therefore, one reaction may be to see the case of the Bristol three as an example of the medical profession protecting its own. But that would be a mistake. The fact that the GMC bought the case in the first place was in itself a powerful signal to the medical profession as whole that its members are responsible not only for ensuring that they are competent to carry out the work to do but also for bringing failures of their colleagues to light.

If the verdict has been less than clear cut, it is not because of a medical conspiracy. It is because ensuring that doctors are competent is a difficult task. The importance of the Bristol case therefore lies as much in the pointers it provides for future policy verdict actually reached.

First, the case of the Bristol three is a reminder that the GMC is not designed to deal with institutional failure, as distinct from the failure of individual doctors. Many of the problems at Bristol seem to have been institutional in character, contributing to the deaths of the babies in question. The culture of the Bristol Royal Infirmary apperas to have been somewhat inbred. There was an unwillingness to address openly the disquiet about outcomes, particularly when it was expressed by newly appointed consultants. Criticism was discounted; signals were ignored.

But the GMC cannot put institutions on trial. Nor can it conduct a wide- ranging inquiry, reviewing all the available evidence. It was hearing specific charges against individual doctors, and only the evidence deemed relevant to these charges was heard at the trial. One conclusion may be that in cases where there is widespread disquiet, a wide ranging public inquiry is the best response.

The evidence given during the case also raises some wider issues, ranging beyond the remit of the GMC. The doctors operating at Bristol were not specialised paediatric surgeons. They were operating on a small number of babies. They did not have a dedicated unit or team; they were working on a split site, with babies having to be transported to one hospital to another. So why were the babies not operated at one of the highly specialised hospitals with a much better record?

One answer is, of course, that it is impossible to ensure that all patients are treated by the best surgeon operating at the best places. But if so, what can be done to minimise danger? One response would be to ensure that surgeons receive adequate training before embarking on procedures new to them but already well established elsewhere. This has been done in the case of minimally invasive surgeon. The Bristol case underlines the need to do so more generally. The Bristol case also carries a further message which is that defining competence is a difficult task. In the evidence given at the trial, there was a general acceptance that the results fell below the best and that there was a need to improve performanc e: in fact, a specialised paediatric surgeon was eventually appointed. But when does a less than brilliant performance become unacceptable? When should a surgeon stop operating? The various expert witnesses could not agree. All they could agree was that there are no benchmarks against which performances could be measured. Clearly the medical profession faces a major challenge - to devise the standards against which the performance of individual practitioners can be assessed. This is clearly an urgent task for two new bodies promised by the Government - the National Insti tute for Clinical Excellence and the Commission for Health Improvement. If there was any doubt about the need for such bodies, the Bristol case has dispelled it. The Bristol case was concerned with a particularly high risk area of medicine. The surgeons involved were carrying out what one of the expert witnesses described as a particularly "unforgiving" procedure on very small babies, demanding an extraordinarily high degree of skill and confidence. Failure is both more highly visible and tragic in its consequences than in the case of most medicine. If doctors over-prescribe or make poor diagnoses, the implications are likely to be less dramatic. Ensuring competence in the bread and butter business of medicine is likely to be a more subtle and also more difficult task than ensuring competence in heroic surgery. In the last resort, there can be no substitute for doctors themselves to audit and mon itor what they anbd their colleagues do as a matter of routine. And the GMC trial, for all the ambiguity of the outcome, should send a powerful message to doctors about their responsibilities in this respect. On this crucial point, there is no ambiguity.