The Bristol baby deaths case has set the current agenda for debate on quality monitoring.

Mark Gould reports on the British Association of Medical Managers' annual conference

The man tipped by many to become the next chief medical officer, Professor Liam Donaldson, regional director for Northern and Yorkshire, believes the Bristol baby deaths case has left all clinicians and managers to reflect on the quality of their own early warning systems.

In his address on 'responsibility' at the British Association of Medical Managers' annual conference Professor Donaldson, said: 'We are not terribly good at detecting failures in standards of care.

'Look at Bristol and how long that ran without open recognition of the problem. That is often the case with smaller-scale problems. A lot of people would have known about them, but they are not formally detected and recognised until late in the day when the damage has already been done.'

The NHS was not good at systematically analysing the many factors involved in a problem, or developing protocols for investigating so that lessons could be learned.

And fears about complaints and litigation often obscured the root of the problem.

'We are quite good as a service at taking early corrective action but we are not very good at sustaining it. History often repeats itself, sometimes in the same organisations, and that is a weak area.

'We are not particularly good, either, at dealing with the consequences of serious failures in standards of care. We are not sure how to deal with the victims. We are tangled up in worries about litigation - whether admitting too much is going to lead to fiercer litigation.

'If we want to prevent quality failures we have got to remedy some of these weaknesses.'

He said the publicity generated by Bristol had thrown into relief the whole question of the public's right to quality care.

Professional opinion and media commentary on the Bristol situation had raised a huge problem: 'what if the driving force is that everybody should be able to go to the best place in the country?'

It brought the threat of the adverse outcome that people may not access the best care. Clearly that was an issue for the longer term, he said.

BAMM chair Peter Lees, research and development director at Southampton University Hospital trust, had opened the conference with a warning. As the case against surgeons James Wisheart and Janardan Dhasmana was about to reconvene at the General Medical Council this week, he said, health minister Alan Milburn and other speakers, including GMC president Sir Donald Irvine, were unlikely to say much about it. But they did.

Mr Milburn said events at Bristol showed it was not enough merely for individual clinicians to know their comparative performance figures. And he warned that new quality measures would include a trigger mechanism to ensure GMC involvement if figures showed that a doctor was falling dangerously behind.

He said the buck would stop with a senior clinician. 'In NHS trusts and primary care trusts there will be a senior clinician locally responsible for clinical governance.

'Primary care groups will have to demonstrate that they are putting clinical governance in place if they want trust status.'

He said the Bristol case, and the cervical cancer screening failures at Exeter and at Kent and Canterbury, had damaged public confidence in the NHS.

'These cases illustrate all too clearly in the public mind that internal scrutiny within each hospital is not enough.

'Public confidence will only be restored and patients will only be safeguarded when these processes are supplemented by open and external review,' he said.

Steve Tomlinson, dean of Manchester medical school, was worried that a quality framework covering conditions or diseases such as diabetes, which required a team-driven approach, did not lend itself to clinician- by-clinician comparisons.

Mr Milburn agreed there was still 'a huge amount' to do to make sure meaningful comparisons were being made. He was sure that comparators would recognise that some work was carried out by teams.

'But the starting point is that the patient has a right to know. The patient does have the right to know and that is what we are going to do in partnership with the profession.'

Taking questions, Mr Milburn clinically dispatched Andrew Vallance-Owen, medical director of BUPA, who wanted assurances from the government that 'the quality agenda must apply across the NHS and private sector'.

'My top priority is the NHS and to ensure the best quality of the NHS.'

Despite Mr Milburn's uncompromising words, and the glaring gap in the credibility of self-regulation in the wake of Bristol, Sir Donald Irvine seemed surprisingly chipper when he took the stage.

He told his audience of fellow clinicians that 'despite all the ups and downs' (he meant Bristol, Exeter, and Canterbury) the public had tremendous faith in doctors, and self-regulation was the only way forward.

But he agreed that the GMC had to take a lead and not remain in the minds of most doctors as 'that place in Hallam Street'.

'There is scope for radical and fresh thinking. Instead of being inward-looking about the strict interpretation of the medical act we have to turn that around and engage the public and the profession.

'In so doing we must be proactive rather than reactive and ask the question: are doctors up to their jobs?

'We must not allow medicine to become tyrannised by clinical standards or clinical guidelines. They are there to be a help. They may be mandatory but as long as a clinician can justify his or her actions then they will be free from any GMC action.'

The GMC wanted new relationships to be forged between clinicians and managers but, Sir Donald said, there was a lot of lip-service paid to teamwork. 'You can't provide modern medicine in isolation.'

He added that it was refreshing and invigorating to have your clinical work held up for professional scrutiny.

'When I was a trainer in Newcastle we had a visit from some American medical students. It was quite unnerving to hear one young woman say, 'Don, that was a real bum decision you made there'.'