Three years and £14m later, Professor Rudolf Klein asks whether the cost of the Bristol inquiry represents money well spent

It was the longest, and most expensive, course of psychotherapy in the history of the NHS.

Spending£14m over almost three years, Professor Ian Kennedy's inquiry into children's heart surgery at the Bristol Royal Infirmary has certainly succeeded in achieving its primary aim: it has ensured, in the words of the report, 'that all those affected by the events under investigation can feel that their concerns have been aired and heard and that life can move on'. The sense of tragedy lingers on but, to quote the report again, 'the process of healing' can begin. Both the parents of the children who died and the public at large have been reassured that nothing has been swept under the carpet and that everything has been subjected to a rigorous scrutiny. Possibly even 'a form of communal catharsis' has been achieved.

But, psychotherapy apart, was all the effort, time and money that went into producing the report well spent? For there is a paradox at the heart of it. It delivers both less and more than appears at first sight.Media attention inevitably seized on the account of events at Bristol between 1984 and 1995 and the raft of recommendations designed to end the 'club culture' of British medicine. In both these respects, the report offers surprisingly little that is new. It fills in the details of the Bristol story and endorses a variety of suggestions for change that, for the most part, have become part of the conventional wisdom since the Bristol tragedy first broke on the national consciousness.

So one conclusion might be that the inquiry was too drawn out: that a shorter, sharper (and cheaper) exercise might have had a greater catalytic effect.Yet in one respect, the report is more challenging than it appears at first sight. It identifies what it claims to be a basic flaw in the design of the NHS: the disjunction between ends and means. Successive governments have willed the end (excellence) without providing the resources required to achieve that goal, the report argues, leaving it to service providers to deal with the resulting tensions - of which the Bristol tragedy is, in part at least, a product and a symptom. The result is, in the words of the General Medical Council's evidence to the inquiry, a 'make do and mend' culture in the NHS, exploiting the preparedness of professionals to sacrifice themselves, while exhausting them.

The proposals for separating the management and the regulation of the service flow from this diagnosis. The radical implications of adopting these recommendations need to be stressed. In effect, establishing standards of quality, independent of decisions about resources, would allow the adequacy of funding to be measured against those standards. 'Only by making explicit that which has been implicit will the interest of the patient and public be served, because they will then know what's what, ' the inquiry team contends.

Governments would no longer be able to make promises about improving standards without also providing the necessary resources.

The following concentrates on analysing, and criticising, both the diagnosis and the prescription.

But first let me justify my contention that in other respects the report has little new to say.Here the best starting points are the 1998 hearings before the GMC of the case against the two Bristol surgeons and the trust's medical general manager.No-one who followed these proceedings can be surprised by the findings of the inquiry. The evidence given to the GMC showed that the conduct of the three doctors reflected a wider institutional malaise.

1Itsuggested (and the inquiry amply confirms the point) that the BRI was an introverted and complacent institution, dominated by a number of long-established consultants reluctant to question the performance of one of their number or to listen to anyone who did so. There was a reluctance to confront poor results and a lack of institutional selfcriticism. Further, the GMC hearings showed that the environment in which the children were operated on was inimical to success: there was no dedicated team and the site was split between the Royal Infirmary and the Children's Hospital.

The Bristol inquiry has filled in the details without changing the main features of the story. Its statistical analysis shows that there were 30 more deaths in the years in question than would have been expected if Bristol had performed according to the national average. It raises questions about why Bristol was designated a regional specialist centre in the first place and why, subsequently, noone monitored its performance. It questions the passivity of the trust's non-executive members, the Royal College of Surgeons and the Department of Health. It documents that Bristol was operating with fewer specialists and nurses than considered desirable at the time and that there were problems of co-ordination between different clinical directorates.

In all this, the report is at pains to emphasise that Bristol should not be seen as the story of two arrogant, rogue surgeons: that the conduct of the surgeons should be seen as part of a larger pattern. In a sense, the report implies, the surgeons were the victims of a medical culture that discouraged open discussion of shortcomings (the 'club culture'). They were the victims, above all, of an NHS culture that encouraged heroic endeavour against the odds and the acceptance of inadequate resources as the norm.

In effect, the ethos of 'getting by', the dedication of health professionals to do their best, even with inadequate buildings, staffing and equipment, becomes the enemy of excellence. Bristol, on this interpretation, becomes the symbol of fundamental flaws in the ethos and organisation of both the medical profession and of the NHS.

From this emerge the 198 recommendations of the report: a somewhat self-indulgent prolixity likely to dilute its impact.

2In making these, the report is largely riding the waves of change that followed Bristol. Indeed, the report recognises in its warning against using hindsight in judging events at the infirmary that there has been a transformation in attitudes in the intervening years.Advocating a no-blame culture of openness, changes in medical education, the regular revalidation of all professionals (including managers) in the NHS, improvements in information systems and the reform of the clinical negligence system no longer breaks new ground.And the view that chief executives should be given more breathing space to run their affairs - and that central government should exercise 'much greater self-discipline' instead of making managers 'sacrificial lambs' to achieve 'some quick political fix' - is widely held, though possibly not by ministers.

So we come to what I see as the inquiry's most radical and challenging theme: the separation of management and regulation. The report's argument for so doing runs as follows. On the one hand, 'it is inevitable and right that central government should seek to lay down the parameters of the NHS's activities, particularly in the realm of finance and priorities'. On the other hand, 'once this is done, the systems for monitoring the extent to which it is meeting its stated aims must, in our view, be depoliticised, so as thereby to rekindle and maintain public confidence'.

Hence the proposal for strengthening the role of a battery of regulatory bodies and making them independent of government. The National Institute for Clinical Excellence would devise and set the standards; the Commission for Health Improvement would monitor performance and 'validate' healthcare providers. In addition, the proposed Council for Health Care Regulators would be responsible for supervising the various regulatory bodies responsible for individual professions.

There are problems, both practical and constitutional, with implementing these proposals, however. Consider NICE. There is indeed a strong case for rationalising the standard-setting industry and making one body responsible for co-ordinating and issuing guidance, so replacing the cacophony of advice coming from royal colleges, specialist associations and the DoH. But when the report sets out the dimensions of the required standards, doubt begins to set in. These should include, it argues, timely access to care, the allocation of responsibilities between primary, community and hospital care and physical facilities.And in all this, patients and the public must be 'fully' involved.

One reason for doubt is the sheer scale and difficulty of the proposed exercise: a heroic enterprise.Also, while the rhetoric of patient and public involvement is easy, translating it into reality is less so: it is notoriously difficult to find 'representative' patients or members of the public, given the heterogeneity of both.More fundamental still, the proposed role for NICE would appear to leave little scope for managerial or political discretion.Once the experts and the public had spoken - through the voice of NICE - that would be the end of the matter. In effect, therefore, the inquiry's recommendations are a recipe for limiting the role of politics in the NHS.And while many will see this as a wholly desirable aim, it is difficult to reconcile it with the fact that the NHS is accountable to the health secretary and to Parliament.Nor is it self-evident, as the report fugitively recognises, that standards can be set without regard to their resource implications: indeed, divorcing responsibility for setting standards from responsibility for meeting the bill could be seen as a formula for ever-escalating spending on the NHS.While some (including the members of the inquiry) might welcome this prospect, it cannot be assumed that it is compatible with the present system of funding healthcare in the UK: the attraction of the NHS model to all governments, and especially chancellors of the Exchequer, is precisely that it allows them to control costs.

The case of CHI is different. There can be little quarrel with the report's recommendation that CHI should develop its capacity to monitor the performance of healthcare organisations using comparative statistical information. But the proposal that it should become a 'validating' body - determining whether a particular hospital should be allowed to carry out specific procedures or provide particular services - is more questionable, if understandable, in the light of the evidence that Bristol was carrying out operations beyond its capacity to do so safely. It is far from clear that CHI has the capacity to take on the extra, potentially enormous, burdens that would flow from this recommendation.Nor is it clear how regulation and management would mesh: if anything, the implication is that management would simply have to accommodate the regulators' decisions about what is to be done where.

There are other difficulties with the inquiry model.

Ensuring the independence of the regulatory bodies - dependent as they would remain on government funding - might not be a straightforward exercise.

Nor is it clear to whom the regulators would be accountable. But these are reasons for caution in exploring the radical implications of the recommendations rather than for rejecting them outright. Furthermore, two assumptions underlie the model that need to be challenged.

The first is that improving NHS standards necessarily requires extra spending. This is to ignore that the wide variations in NHS standards do not always reflect variations in the resources available.

Equally, they reflect variations in the capacity to manage those resources, as documented in a succession of reports from the Audit Commission (whose remit the inquiry wants to restrict). The paradox of the NHS is precisely that while health professionals do feel frustrated by the resource constraints limiting their ability to achieve the excellence to which they aspire, they frequently contribute to the pressures on the service through their own patterns of practice. So while spending more may be a necessary condition, it will certainly not be a sufficient one.

The second general point to be made about the report reinforces this caution. Its assumption appears to be that the causes of the Bristol tragedy are to be found in the specific circumstances of the NHS. This is far from the case. Scandals revolving around poor practice, and preventable deaths, are an international phenomenon.Other healthcare systems offer plenty of examples of mishaps caused by lack of openness, failures of team-work and inadequate monitoring. So maybe the focus of the initial reaction to the Kennedy report, concentrating as it did on the recommendations that dealt with the need to change professional culture, was the right one. This is not a comforting conclusion since, as the whole history of the NHS demonstrates, it is easier to invent new institutions and organisational fixes than to change attitudes.

Key points

The Bristol inquiry highlights the disjunction between ends and means in the NHS.

It draws attention to the 'make do and mend'culture in the service.

The ethos of 'getting by' is seen as the enemy of excellence.

Its most radical theme is the separation of management and regulation.

REFERENCES

1Klein R. Regulating the medical profession: doctors and the public interest.

Harrison A (ed). Health Care UK, 1997/98. King's Fund, 1998.

2Smith R. One Bristol, but there could have been many.

Br Med J 2001; 323: 179-180.

Rudolf Klein is visiting professor at the London School of Economics and at the London School of Hygiene and Tropical Medicine.