The listening blank

The Bristol Royal Infirmary inquiry is, in many respects, a watershed in British health policy.

It addresses not just the treatment of individual patients in one hospital but also the whole structure, management and funding of the NHS over an 11-year period. It is a comprehensive and challenging analysis that has already had a major impact on government thinking.

The inquiry also raises important questions about accountability, leadership and clinical management as well as the quality of care. It is the first time in the history of the NHS that a prestigious acute teaching hospital has been subject to such scrutiny and the first time that such a detailed investigation has been undertaken under the public gaze.

However, there are some curious lapses. Though the inquiry was at pains to set the events at BRI in a broader context, it is dismissive of lessons that could be learned from earlier NHS inquiries. It complains that the NHS is 'littered'with reports that were 'consigned to gather dust on shelves.' They had little impact, it maintains, because they were overly simplistic and looked only for individuals to blame. In fact, there are many common themes about structural and organisational failure. These are reflected time and again in the Bristol report.

The implication that Bristol's status as an acute teaching hospital and tertiary centre set it apart is incorrect and, if we are truly to learn lessons and to change practice, we must draw upon historical evidence as well as our understanding of what went wrong at Bristol.

The first of a series of inquiries into failures of care was prompted by a letter to The Times in 1965 from a group of peers, clergymen, campaigners, academics and social workers. It complained of the shocking treatment of 'geriatric patients in certain mental hospitals' and the casual attitude of the Ministry of Health in dealing with complaints. The authors of the letter were so frustrated at the ministry's refusal to act on their concerns that they began to collect data from hundreds of nurses, social workers, patients and families and, in 1967, published a book entitled Sans Everything.

2It illustrated the neglect and cruelty that they claimed were commonplace. In his foreword to the book, Dr Russell Barton made several observations that resonate with the findings of the Bristol inquiry.He claimed that NHS hospitals, and the people who work in them, responded in a number of ways to complaints about failures of care. They would deny the problem or dismiss the evidence as ill-founded. They had a tendency to lie low and hope the criticism would fade. They discredited and victimised complainants, implying malice or 'pathological zeal'. They sometimes developed a Joan Higgins is director and professor of health policy, Manchester Centre for Healthcare Management, Manchester University.

'neurotic self-propagating tradition' of misplaced loyalty to colleagues, which meant no-one had the courage to 'rock the boat'.

The publication of Sans Everything at last prompted a response from the ministry. Private investigations, led by regional hospital boards, were conducted in six hospitals identified in the book as 'failing'.However, the results were a disappointment to the campaigners.

The incidents they described were largely dismissed as isolated events or failures of care on the part of individual clinicians who had subsequently retired. The campaigners were described as sincere but amateurish, overemotional and ill-informed.

What happened next was less easy to dismiss. In July 1967, the News of the World published allegations of 'staff misconduct' by a nurse at Ely Hospital in Cardiff. The misconduct included cruelty to patients, threatening behaviour, theft of patients' food and clothing, indifference to complaints and a lack of care by the physician superintendent and another member of the medical staff.

This time the minister of health established the first of the 'modern' inquiries that ultimately led to Bristol. The Ely inquiry was chaired by a distinguished lawyer, Geoffrey Howe QC - who was later to become a leading Conservative politician - and worked rapidly. It sat for 15 days (in contrast to the three years of the Bristol inquiry) and produced a report of 135 pages.

3Though the inquiry was held in private, the members of the committee went to considerable lengths to encourage witness statements and the submission of evidence. They also spent significant periods in the hospital.

Like other inquiries, the Ely report targeted the whistleblower for criticism.As in the case of Bristol, he was not British.He was described as a 'rolling stone'with 'a grievance against the world'. The committee observed that 'he did not seem to have a natural enthusiasm for hard physical work' and was a man 'who tended to make beds with one hand in his pocket'.Nevertheless, he was largely vindicated by the inquiry and his allegations were substantiated.

Like Dr Stephen Bolsin (the Bristol whistleblower), he was reproved for his style and approach but was found to be credible and accurate in his criticisms of colleagues and the service they provided. This tendency to victimise the whistleblower has characterised virtually all the inquiry reports since Ely. Even where informants have genuinely exposed poor or dangerous practice there is a strong tendency to criticise the manner in which they have done so.

It is little wonder that NHS staff are reluctant to report bad practice when they are subject to slurs and asides, even when vindicated.

The Ely report focused on a range of issues that were investigated in the Bristol inquiry more than 30 years later. They include problems of medical leadership, a lack of clarity of leadership roles, a failure to act upon complaints, a lack of understanding of modern clinical techniques, inadequate monitoring by the board and what the Bristol report describes as a 'club culture'.

What this should tell us is that BRI was not fundamentally different from other NHS hospitals, even though it was a prestigious teaching hospital and a tertiary centre. Ely was an old Poor Law institution caring largely for people with learning disabilities and older people with mental health problems, but the commonalities are striking. The failure to provide effective, appropriate and humane treatment to some groups of patients originates deep within the fabric of the NHS and cannot be attributed simply to individual clinicians or institutions.What the similarities between Ely and Bristol also tell us is that we have to be exceptionally tenacious in responding to the Bristol inquiry recommendations.

Thoughtful, incisive recommendations have flowed from reports for more than 30 years, but familiar problems still persist.

Since the Ely inquiry in 1969, more than 30 reports from other NHS inquiries have been published. The very names evoke memories of cruelty and abuse in services designed to protect the weak - Farleigh, Whittingham, St Augustine's, South Ockendon, Normansfield, Brookwood, Napsbury, Rampton and so on.

4The reports have focused primarily on the care of older people and people with a mental illness or learning disability. The common thread within these groups is low status, vulnerability and invisibility. The Bristol inquiry has concluded that children and children's services in the NHS are also low status and low priority.

All of these inquiries point to five key factors that lead to failures of care in organisations: isolation, weak leadership, systemic failure, poor communication and vulnerable groups. Each was present in Bristol.

Isolation Sometimes this is geographical isolation, as in the case of old hospitals for mentally ill people. But in most hospitals it is a case of being 'out of the mainstream', unexposed to current thinking and modern clinical techniques. This is not an image normally associated with a leading teaching hospital, but the Bristol report demonstrates that isolation can be a problem in any setting.Younger clinicians at BRI felt their older colleagues had been 'left behind by recent developments, were slow and reluctant to change and were in something of a backwater'.

Inadequate leadership Most of the inquiry reports talk of a weak or bullying leadership, or of a lack of leadership.

Usually, as in Bristol, the finger points at failures of clinical leadership. The problem often lies with doctors, and sometimes nurses, in senior management roles. In the early days, it was the physician superintendent who came in for criticism. In Bristol it was the chief executive, who happened also to be a doctor, and his senior medical and nursing colleagues.

The particular accusations levelled at former BRI chief executive Dr John Roylance and a number of senior staff were that they ignored complaints, they concentrated power in the hands of a small number of individuals, they fostered a 'club culture'which excluded many staff and they consistently failed to respond to a mass of evidence about poor clinical care in paediatric cardiac services.

Failures of systems and processes The authors of the Bristol report are at pains to point out that the blame for what went wrong cannot simply be laid at the door of individuals. Like the previous inquiries, Bristol talks about underfunding, poor audit systems, ineffective complaints systems, a lack of consistent data on clinical performance and standards of care, and inadequate buildings and equipment. They emphasise systemic failure, as well as the failures of individuals.

Poor communication The focus in Bristol was on the need to improve communication between patients and staff, the importance of informed consent and the demand for better information for patients and their families about treatment options, prognosis and likely outcomes. Some families were entirely satisfied with this aspect of care. Progress in providing effective communication has been made since Ely. Thirty years ago, the relationship between doctors and patients was so unequal that patients had no, or extremely low, expectations of receiving information about their care. Now, the emphasis is on the quality and availability of that information.

Disempowerment of staff and service users Those groups of the population that cannot communicate effectively on their own behalf are often the most disempowered groups in the health and welfare system. They may be the 'invisible' older person in long-stay care (the 'unvisited' as the Ely report called them) or children who do not have articulate, well-informed parents to speak out for them.

The Bristol report recognises that true public/patient empowerment rests upon good information, adequate mechanisms for inclusion and involvement and a change in the culture of the NHS (to one that sees patient empowerment as positive rather than as a burden).

The Bristol inquiry raises other important questions that must be addressed as the NHS moves into a new era.

Who was in charge of ensuring the quality of children's services?

Following the creation of the NHS market in 1991, there was enormous confusion about who was responsible for assuring the quality of clinical services. This was exacerbated in a tertiary service where innumerable stakeholders were involved. As the report points out, this was 'not just some administrative game of pass the parcel.What was at stake was the health, welfare and, indeed, the lives of children.What was lacking was any real system. . .

for what a lay person would describe as keeping an eye on things'.

What was the role of the trust board in monitoring quality and in tackling problem areas?

The inquiry is decidedly gentle with the board and the various chairs who came and went between 1984 and 1995. It is sympathetic to their claims that they were kept in the dark by the chief executive and other senior managers. Is this justified and are the measures suggested for improving the performance of boards really tough enough?

In 1969, the Ely report recommended that hospital management committee members should be recruited and trained in a more systematic manner.

Over 30 years later, the Bristol report makes essentially the same points.However, the existing training and induction programmes have clearly been inadequate. It is not enough to learn facts and figures about the NHS (though some facts are essential).

The most powerful weapon is comparative data and the most powerful ammunition is a good question. Board members learn this best by mixing with others in similar situations.

They learn to ask 'why do we do it in this way when the trust down the road is doing it differently?' or 'why do not we have this data at our board meetings when others do?' Board members can be the eyes and ears of the organisation. They have friends, relatives and neighbours who work in the service and who use the service. They should be accessible to people who have concerns or complaints. They should feel free to observe every aspect of the service for which they are responsible and they must have the courage to challenge chief executives, and even chairs, who would prefer to keep them in the dark. Nonexecutives will never know what it is that they do not know - and this is one of the frustrations of the job. However, they have a better grasp of what is going right and what is going wrong if they gather their impressions from staff and patients rather than relying on boardroom discussions or training courses to supply all the answers.

Can doctors make effective managers?

This is a crucial question, not just in acute hospitals, but even more so in primary care where hundreds of GPs have recently been recruited to chair professional executive committees in primary care truts. The inquiry is not critical of doctors as managers per se, but of a system that failed to provide doctors with management skills, which allowed them to 'dabble' in both management and clinical practice and which favoured their views above all others.

There is a danger that the report could be used to turn back the clock and to discourage clinicians from taking on management roles. This would be unfortunate and unintended.However, there is a clear need for more management training and skills development plus a support system that will enhance the capacity of clinicians to take part in NHS management.

The Bristol report is profound, eloquent and moving and will be a milestone in the reform of health policy and practice in the UK - perhaps beyond. The present government has already responded in a positive way to many of its recommendations. Though organisational reform is essential, the real challenge is to change behaviour.As Russell Barton stated in the foreword to Sans Everything, in 1967: 'The one thing administrators, committees and many other people fail to learn is that kindness, pleasantness, sympathy and forbearance cannot be commanded by giving orders or passing resolutions. . .

'For most people these qualities develop, or fail to develop, according to the example and manifest concern by senior staff.'

This is, in part, where Bristol went wrong and where we must do better in future.

Key points

The major failures reported in the Bristol inquiry have been highlighted in most hospital inquiry reports over the past 30 years.

The tendency to victimise the whistleblower has characterised virtually all inquiries.

Inadequate leadership, isolation, system failures, poor communication and disempowerment of staff and service users are the common themes.

While organisational reform is essential, the real challenge is to change behaviour.And this depends on the example of senior staff.