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Why Bristol is so important
BBC Health Correspondent Daniel Sandford explains why the Bristol Inquiry has such important implications for the NHS.
There are times when being a Health Correspondent can be a depressing job.
Never more so than when I opened the Bristol Royal Infirmary Inquiry Report today and read the following sentence: "Even today it is still not possible to say, categorically, that events similar to those which happened in Bristol could not happen again in the UK; indeed, are not happening at this moment."
For the last few years we have lurched from one scandal to another.
First there were the deaths of babies following heart surgery at the Bristol Royal Infirmary.
Then there was the Alder Hey organ retention furore.
There was Mavis Skeet who died of cancer because doctors cancelled a life-saving operation five times.
There were successive winter crises with sick elderly patients who had paid for the NHS all their lives lying on trolleys in corridors.
There were Richie William and Wayne Jowett who were both killed by chemotherapy injections that went into their spines instead of their veins.
And there was three-year-old Najiyah Hussein who died in Accident and Emergency when she was given an anaesthetic gas to breathe instead of oxygen.
Now it is Bristol again. Four years after the original General Medical Council hearing, the Bristol Royal Infirmary Inquiry has published its final report.
But Bristol is different. It is different because the scandal marked the moment when many people's trust in doctors first wavered significantly.
It is different because in many ways it started the huge media scrutiny the medical profession now finds itself under.
It is different because it encapsulates many of the things that are wrong with the NHS.
Above all it is different because many of the most fundamental changes to how British doctors are regulated and monitored were born out of the Bristol scandal, and if taken seriously today's report could produce even more fundamental change.
The Inquiry Chairman, Professor Ian Kennedy says that "Patients and their families must be treated with respect and with openness and honesty."
It seems absurd that any health service should have to be told that.
Nonetheless he thought it worth saying and let's hope somebody is listening.
What went wrong?
Janardan Dhasmana and his boss James Wisheart were in many ways highly competent heart surgeons.
But when they started doing certain new operations on babies they were less successful.
And - crucially - they went on operating long after they had lost the support of several of their colleagues.
The Inquiry does not mince its words when it comes to Mr Wisheart it says he "adopted an approach based on optimism rather than reality."
The problem was there was no system for auditing their surgery results.
The stark facts that told the story of their poor performance were there.
As Professor Kennedy so tellingly puts it "Bristol was awash with data from one source or another.
What was lacking was information: some understanding of what the data meant."
But nobody was looking, nobody was collating, nobody was comparing their performance with anyone else's.
So nobody was telling the parents who were consenting to the high-risk operations.
When eventually an anaesthetist colleague - Dr Stephen Bolsin - did an audit of his own he was sent away with a flea in his ear and told not to rock the boat.
The NHS was not monitoring doctors performance nationally, the various medical organisations were not doing it either, nor was the hospital trust.
Then when Dr Bolsin started blowing the whistle nobody except the satirical magazine Private Eye was listening.
Hospital consultants' performances were not monitored in any formal way so nobody could question them.
It was a license to practice bad surgery.
What has changed?
So for the last four years the Department of Health, the General Medical Council, and the doctors' professional bodies have been engaged in an unruly scramble to get their houses in order before the Bristol Royal Infirmary Inquiry Final Report.
So now we have CHI, the Commission for Health Improvement - a kind of OFSTED for hospitals - who will regularly inspect Britain's hospitals.
We have the NCAA, the National Clinical Assessment Authority.
One of New Labour's "hit squads", it is designed to go in and investigate any brewing crisis.
We have the NPSA, the National Patient Safety Agency which will collate information on medical errors.
We have annual appraisals for hospital consultants and a new MOT for doctors - a revalidation system in which they have to prove they are still fit to practice every five years.
Suddenly doctors who have been regulating themselves for almost five hundred years find themselves under intense scrutiny from a huge array of organisations.
Will it work?
So will all these new bodies and systems make any difference?
Well the answer is almost certainly yes. The sheer level of scrutiny is bound to pick up things that might have previously slipped through the net.
There is still no single organisation whose responsibility it will be to make sure that a doctor's performance is up to scratch.
Which is why the inquiry is recommending two umbrella organisations.
The proposed Council for the Regulation of Health Professionals would oversee the General Medical Council and the new Nursing and Midwifery Council.
A Council for the Quality of Healthcare would take in organisations like CHI and the NPSA.
But the chances of something going badly wrong will be diminished.
A more radical approach?
The most controversial recommendations in the report cover the desire to create a climate of greater openness.
The Inquiry makes two radical proposals, that the system of clinical negligence litigation should be abolished, and that any member of staff who reports an unexplained death within 48 hours should receive immunity from disciplinary action.
They are breathtaking suggestions that will face enormous opposition, not least of all from lawyers.
They are certain to generate a fascinating debate over whether we want to sacrifice the opportunity to sue the NHS when it kills our relatives in the hope that the health service will be more open about its mistakes.
More bad news?
One unpleasant side-effect of all this openness will be the nasty things that crawl out from under the stones.
We all have to prepare ourselves for a steady stream of new scandals that might have otherwise gone unnoticed.
It's going to be another depressing few years for Health Correspondents.
Meanwhile the vast majority of people treated in the NHS will be seen by highly-skilled doctors and get treatment that is close to the best in the world, but you will have to go on taking that as read. It is the scandals that will make the headlines.
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