The likely impact of the recent Bristol inquiry on the future of health politics in the United Kingdom
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In October 1997 an inquiry began into the deaths of fifteen children whilst undergoing or shortly after receiving cardiac surgery at Bristol royal infirmary (BRI). The report was finally published in June 1998 and proved to be the most thorough and long running investigation since the inception of the NHS with the surgeons involved found to be guilty of professional misconduct. The consequences promise to be far reaching as Government led initiatives to improve NHS quality and to prevent a repeat of such a scandal have taken place.
The most likely impact upon the NHS will be that databases of cardiac surgery will be made available publicly with increased openness and transparency. Change will only be successful if co-operation occurs between all involved. Cardiac surgeons Janard Dharasmana and James Wisheart along with BRI district general manager John Roylance were found by the General Medical Council (GMC) to be guilty of professional misconduct. Concerns were raised about child cardiac surgery and were found to be justified when compared with other units, (www. spiked-online. com).
It was collective and institutional failure at Bristol which proved to be most alarming. The surgeons had failed to examine their own performances, and colleagues whom had been alerted by worried doctors failed to take action. The Bristol inquiry aroused mass press interest and strong differences of opinion from all concerned, (Klein, 01, pg209). The publicity, which surrounded the inquiry, increased knowledge of paediatric surgery making it less appealing for some. There may be a reluctance to carry out high-risk procedures, whilst surgeons may leave the field, others may be deterred from entering.
This could lead to reduced death rates throughout the United Kingdom, lowering the cost on the NHS. The new Bristol Royal children’s hospital, which opened last year, has among the best survival rates in the country, (Savulescu, 02). The enquiry should lead to a revised ethos within the NHS away from the culture of secretiveness. This is bound to be met with stubborn resistance from some staff members. The NHS will allow the public in and work with them which will reveal shortcomings, but ultimately will be necessary and will be beneficial in regaining trust.
The aim is that healthcare professionals will recognise under performance and will then implement plans to improve. Public confidence will surely be raised with patients able to make informed choices on children’s treatment by the news that child heart surgeons have said that they would be willing to publish data on success rates. The British Paediatric Cardiac Association (BPCA) has agreed to allow audit teams which will include parents to visit child heart centres, Professor Robert Anderson has said, “The consensus within the BPCA is that within the near future all centres in the UK will publish their results in the public domain”, (www. uardian. co. uk/archive).
The inquiry highlighted the need for detailed records of operations and outcomes to be kept, this has seen pressure grow for the formation of computer databases of all paediatric cardiac operations and implementation appears to be near. The Bristol inquiry illustrated the inadequacies of the system of monitoring healthcare quality that exists in the United Kingdom, and greater attempts will be made to improve upon this. Since the inquiry the notion of “clinical governance” has required all trusts to set up a system for examining standards and identifying and remedying poor performance.
The report itself identified confusion at national level as to who was responsible for monitoring care, which . cost the lives of young children. No organisation was in place to take any form of responsibility, and the system has been criticised for being “non- existent”, (www. bristol-inquiry. org. uk/final-report). No longer will audits be a voluntary procedure, as a result of the Bristol inquiry doctors will be regularly and routinely checked upon with a more efficient system implemented.
The age of “clinical governance” has brought with it mechanisms by which colleagues are able to alert health authorities if for example a surgeon is producing poor results, without arousing the sort of antagonism of the “whistle blower” accorded to Dr Bolsin in the Bristol affair. The inquiry will therefore have the likely impact of introducing stringency upon the performance of individuals to a degree unprecedented in the history of the NHS, (Klein, 01, pg212). Out of the enquiry the commission for health improvement emerged.
The role of the commission is to asses and review the quality and availability of health care, as well as examining management. It is planned that within four years of the enquiry that every trust in the country will be reviewed and the results published. This will give the public a greater understanding of the workings of the health service and indeed its areas requiring improvement. This will inevitably result in a more knowledgeable public who are ultimately the consumers of the NHS product.
Expectations should also become more realistic and achievable, (www. bbc. co. k/hi/english/health) Procedures for detecting and dealing with performance issues have been criticised as being inflexible, fragmented, and lacking cohesion. So a further initiative was advanced where doctors will now be referred to assessment and support centres instead of the pre- Bristol methods of disciplinary procedures and yearly appraisals. The inquiry therefore will lead to a significant increase in personal examination of doctor’s work and possible issues of performance. The process was given additional impetus due to the conviction of Dr Harold Shipman for the murder s of fifteen elderly patients, (Klein, 01, pg213).
At the launch of the commission for health improvement the Prime Minister Tony Blair made comparisons between it and OFSTED the much maligned organisation responsible for maintaining education standards in England and Wales. He commented, “As OFSTED is playing a crucial role in driving up standards in schools so the commission will drive up standards inn health care”, (Blair as cited in Klein, 01, pg211). Such a comparison was however rejected by the commission who sought to avoid such generalisations. The isolated issue of Bristol had induced a state response.
It was argued that such a body was a must to restore public faith and improve the standard of health care throughout the country. It is impossible to predict just exactly how the NHS will change as a result of the inquiry, due to it being so recent. Though those concerned can feel confident that radical change will occur. The definition of the term “professionalism” will be altered as a result, and greater emphasis on self-regulation will take place. It has been proposed that doctors may need to take part in revalidation, in essence a form of MOT for doctors.
There has been very little opposition to the Governments proposals, and it seems that advancements and structures have been secured which will closely examine the work of Professionals employed by the NHS, decreasing the likelihood of such a tragedy as happened at Bristol reoccurring, (www. guardian. co. uk/archive). The relationship between professionals and patients should change as far as a result of the inquiry. Doctors will be expected to adopt a more open and modern style of communication as opposed to the paternal and defensive attitude assumed by many.
This will apply in everyday dealings with patients, to responding to concerns and complaints when things don’t go according patients expectations. Information regarding planned treatment, outcomes, and conditions could be presented clearer and on request, patients should be regularly updated. The patient doctor relationship is the most indicative of the success of the NHS and if this becomes more honest and frank then it would suggest that a favourable future for all concerned will result, (www. bristol-inquiry. org. uk).
The Bristol inquiry therefore concluded that health care professionals had adopted unsuitable attitudes when dealing with patients and parents. It stated that many doctors were immersed in petty rivalries with fellow colleagues, which resulted in substandard health care and the death of the children, which could and should have been avoided. The Bristol situation caused a real depression within the NHS, and one that will not be forgotten, as the repercussions will be huge, representing in effect a revolution of the medical profession, which will be regulated much more thoroughly.
The Government in response set plans in motion for the commission for health improvement and clinical governance, which should restrict the possibility of such an episode ever recurring and help restore public confidence. Health politics throughout the United Kingdom in future promise to be more open to effective investigation and closer checks upon individual performances. It appears the mechanisms are in place, which will make a repeat of such a disaster highly improbable.