'Bristol has completely reorganised the way we think' Alison Moore asked key figures to examine the impact of Bristol on the wider NHS

He retired from the Department of Health in 1994 'T here were two units where referrals were particularly low - Newcastle and Bristol.

Newcastle is now one of the leading units in the world.

The staff there have changed, but not significantly - the people who were the leaders then are the leaders now.Now, with the benefit of hindsight, you can see there were problems with Bristol but not any significant problems with Newcastle.

My relations with the consultants in Newcastle were better than with ones in Bristol - they were more forthcoming.

Newcastle was more communicative than Bristol.

One of the difficulties we had in the 1980s and we have now is carrying out medical audit. At the time I was head of the division, the Department of Health's view was that medical audit was not a matter for the department... I opposed that.

How do you interpret the information you get? It was very difficult then and very difficult now. The Bristol inquiry set up its own audit with unlimited resources and still got it wrong.

Bristol has identified the difficulty of auditing units - I do not believe anything we are doing now is foolproof. There are weaknesses, it is costly and it may not work.

Professor Bob Anderson, president of the British Paediatric Cardiac Association, gave evidence to the Bristol inquiry.He is a research professor at Great Ormond Street Hospital 'B ristol has totally reorganised the way we think: the whole culture has changed.

The other huge thing that has come out already, which has impacted on our own practice, is the furore over organ retention. It has crystallised the fact that we had lost touch with the current day needs of patients.

We have been working hard to remedy this.

We are in the process of drafting model guidance for the treatment of children with congenital heart disease.

Together with the Child Heart Federation we are working on a plan to make sure that there is a partnership between parents and professionals, as we take children from diagnosis to treatment.

Another effect has been on audit.

From April 2000-01 we have collected the data on every procedure done in the UK for child cardiac surgery and cardiac intervention.

At the moment we are only collecting mortality figures, which is less than adequate, but you have to start somewhere.

We recognise that we have lost the trust of patients in the aftermath of Bristol. To regain that trust, we are redoubling our efforts.

But we have to draw a line in the sand and say that we simply can't do any more.Morale is dropping and dropping, and we face a manpower crisis in cardiac services.

We are being asked to do more and more by the Department of Health with less and less resources. I do not believe that Bristol could happen again in the setting of paediatric cardiac services... it has been a jolt to the whole profession.

I am immensely proud of the effort that all my colleagues have put in.

It has not been easy for these people - many of them have put their whole life into treating children, and to realise that some of the things they have been doing are less than adequate is hard.

Dr Chris Bayliss is former chair of the British Medical Association's clinical and medical directors'sub-committee.He is a consultant radiologist at the Royal Devon and Exeter Hospital

Bristol has just generated a huge amount of regulation - everything from the General Medical Council and revalidation to the Commission for Health Improvement- There is hardly time to see any patients because we are being regulated so much. It would be appropriate to have a system of regulation, but I think having about six different groups under different names going at it from different directions is a bit over the top.

Remarkably, the public feel that what happened in Bristol - or the Rodney Ledward or Harold Shipman business or all the others - is so unusual, so extreme, that their faith in the medical profession and doctors does not seem to have been significantly shaken. Certainly in my practice I have not encountered any change.

Whistle-blowing has, I suppose, become safer. I think it very much depends on whether you have gone down all the right roads before you have blown the whistle. There is also the potential for malicious whistleblowing.

Could Bristol happen again?

Absolutely - not a shadow of a doubt. It will never happen in paediatric cardiac surgery, though.

The next one will be something like a psychiatrist slaughtering their patients - you can't predict who it is or where it is.

Dr Jenny Simpson is chief executive of the British Association of Medical Managers There has been a complete change in the culture of the medical profession since Bristol.

People are much more aware of what a management responsibility is and how to discharge it.

It is a serious thing now, rather than something that was under the carpet as then.

But things were changing anyhow... I do not think we have got better at monitoring quality because of Bristol but it and a number of other incidents sharpened the mind.

It is a little bit to do with Bristol but I do not think it was the be all and end all. Clinical governance owes a lot to Bristol, but it was coming anyhow.

The Bristol doctors in their own way - although I would not condone it - thought they were doing their best by the standards and norms of their time.

They were not malicious in intent - they were ill-judged and ill-managed.

Pamela Charlwood is chief executive of Avon HA and gave evidence to the Bristol inquiry 'I n relation to the corporate governance agenda there has been a great deal more awareness around controls assurance and risk management.

But I still wonder how we can assure ourselves that boards are looking at the right things with the right information available to them and assessing them so that action is taken where needed.

There is a challenging question for NHS bodies about the role of boards and the expectations we have of them and their ability to fulfil those expectations.

Where's the thinking around service provision? One of the issues was clearly the provision of children's services, and my view is that we have a great deal more clarity and stringency in providing children's services in settings that are right for children with staff teams that are experts in children's care.

I do not think all of us are 100 per cent there yet, but There is a lot more clarity now. Bristol has a new children's hospital. The chances of Bristol happening again have been greatly reduced.

Alastair Henderson is policy manager at the NHS Confederation 'P re-Bristol, clinical quality was not particularly considered a managerial or organisational concern.The attitude that 'this is not our concern'no longer exists.

There is a change in attitude in clinicians that it is right to be reporting issues, and managers feel they have a duty to pick things up and pursue them. Everything will not always work smoothly.

But we have the mechanisms to ensure if things are wrong the problems are identified as early as possible - ranging from a duty of quality imposed on chief executives, clinical governance, appraisal and revalidation, the national service frameworks, National Institute for Clinical Excellence recommendations, controls on the performance of individuals, the Commission for Health Improvement, adverse reporting systems- Sir Barry Jackson is president of the Royal College of Surgeons 'B ristol has had a major impact on the whole profession, and particularly on surgeons, because it was depicted in the media as being explicitly critical of surgeons and surgery.

There have been some specific concrete measures put in place since Bristol... there has also been a cultural change. It has been brought home to the profession that we had fallen, rather insidiously, into a culture that was not really acceptable for the 21st century.