Public trust is the medical profession's most precious asset.

The tragedy of the Bristol Royal Infirmary affair is that it is likely to erode that trust seriously, and possibly irretrievably. Understandably, in the aftermath of what has happened, there are strident calls for external regulation and tighter controls over what doctors do.

And so the march of the 'audit society' advances yet further, claiming another victim and one that has so far remained remarkably immune from its embrace. The new watchwords of health policy are audit, accountability and regulation combined with a growing insistence that these activities should not remain the preserve of a selfregulating professional syndicate.

We should be war y of taking precipitous action. The issues are complex. The problem is more one of culture and standard operating procedures in the workplace than a lack of external controls.

And although publishing league tables of hospital mortality rates will provide access to important information, it may not go far enough in reassuring a worried public wanting to know who the best performers are and whose scalpel should be avoided. The scenario of GPs besieged by patients insisting on referral to a particular surgeon is not so fanciful.

Yet such behaviour is not compatible with our NHS. The NHS will not be able to survive an onslaught of consumer power, since it is not designed to respond to such signals.

The whole ethos of the NHS is that a broadly comparable level and quality of care is available throughout the service. While this may always have been something of a fiction, we need to understand why it should be so.

The Bristol case, above all, demonstrates a failure of clinical management. It may also indicate the weakness of having a clinician as chief executive although, as the Kent and Canterbury cancer screening fiasco demonstrates, lay chief executives can face similar problems. But the crucial point is that, far from being overmanaged, the NHS is seriously under managed. This does not mean recruiting a new army of 'suits'. What is needed is an acceptance of management by clinicians themselves.

Management externally imposed is not the answer, especially if it is accompanied by strong-arm tactics.

Nor are regulatory devices like the Commission for Health Improvement, which will threaten underperforming trusts with the big stick.

The tragedy of Bristol is that sufficient evidence of what was going wrong existed for a considerable time and was known to a number of clinicians and others, but was not acted on. It was essentially a cultural problem, and until this is tackled, the possibility of a repetition of what happened at Bristol must remain.

As long as doctors are trained to be rugged and competitive individualists there will be no sense among them of a social or corporate responsibility to the public. And yet, as Mechanic has written, trust has two dimensions: the personal doctor-patient conception of trust, and the notion of social trust.

1While the former is compatible with the image of a buccaneering clinician responsible to no one but themselves and their patients, social trust requires a different relationship between the clinician and the NHS of which they are a part, and ultimately the public. It is based on common or shared norms and values.

Medicine is a complex business and if trust is replaced by external regulation it will become ever more cumbersome, complex and bureaucratic. As Mechanic puts it, 'life is impossible without trust. . .

Trust reduces complexity and the need to plan for innumerable contingencies'.

In the absence of trust all kinds of perverse behaviours become possible. For example, high-risk patients may not be operated on for fear of adding to a clinician's death rate and raising questions about their competence. In a climate of suspicion, defensive medicine is likely to take on a whole new dimension.

While an active public can lead to improved, more mature relationships between doctors and their patients, it also risks being disruptive of the delicate balance of power which exists in medical encounters.

Rather than start from a position of suspicion and absence of trust, the problem needs to be turned around so that the aim of any policy or management intervention is to restore public trust and confidence in the medical profession.

The only sure way to restore trust is full and open communication between doctors and patients, and between members of the medical team working in units like the Bristol one. Clearly, there was a serious communications deficit there, with professional arrogance the root of the problem.

Unless, or until, the culture of medicine is tackled from within, external controls are not likely to have much enduring impact. They may satisfy politicians' desire to be seen to be taking tough action and the public's desire to sort out the doctors.

But that is not the same thing as seeking to preserve and strengthen the fragile, subtle mechanisms which are so critical to the smooth functioning of any healthcare system.

Indeed, without them no health service can hope to function effectively. Dependence on trust in the medical profession may not be fashionable in an age of consumerism, but that does not lessen its validity.

Bristol holds many lessons, though its real tragedy is that none is new.

We must hope that the action to follow will be designed not to appease a worried public at any cost, but to have a deep impact on the culture of medicine which breeds the conditions that allow incidents like those in Bristol to occur.

David Hunter is professor of health policy and management at the Nuffield Institute for Health, Leeds University.


1 Mechanic D. Changing Medical Organization and the Erosion of Trust. The Milbank Quarterly 1996 ; 74(2): 171-89.