It should be no surprise that the medical establishment has come under attack - it is arrogant, secretive and unaccountable
DOCTORS learn to keep other doctors' mistakes secret from almost the first day they arrive at medical school. It is part of what being in a profession is all about. George Bernard Shaw's remark that "all professions are conspiracies against the laity" remains all too true in medicine today. It is a scandal that is only now being uncovered.

When I was a medical student in the 1980s I remember a consultant surgeon who took great pleasure in displaying his operating technique. He was a superb surgeon, it is true, internationally recognised for his work. He was a senior member of the Royal College of Surgeons, a venerable institution that began life in 1540 as the Company of Barbers. But his success had bred arrogance.

During one operation I saw him deliberately cut a patient's ureter, the delicate tube connecting the kidney and bladder. Why? Because he wanted to teach a colleague how to repair a damaged ureter, only on this occasion the damage was done intentionally by his own hand.

This sort of practice, and far worse, is not uncommon. A few months ago, a paediatric cardiologist was found guilty of serious professional misconduct by the General Medical Council (GMC) because he performed a procedure on a six-year-old girl - who later died - without seeking consent from her parents. The High Court recently awarded a woman pounds 400,000 in damages after doctors wrongly told her that her unborn baby was dead. Medical academics are increasingly being scrutinised because of alarming cases of outright fraud in clinical research. And the case against the three doctors from Bristol who were accused of appalling and fatal incompetence was found proven earlier this month.

The cumulative effect of these cases has been to damage severely the trust that patients put in doctors. Doctors have been portrayed as reckless and inept. Such a view is unfair and wrong. Most doctors work hard and care deeply about their patients. But, as in any other sphere of life, there are rogues and charlatans among them. What is often forgotten is that the weaknesses of individual doctors reflect much greater failings by the grand institutions that run medicine.

The royal colleges and the British Medical Association deserve particular criticism. The BMA is the doctors' trade union and represents more than 80 per cent of the medical workforce. The colleges are smaller and more prestigious professional associations for specialists - physicians and surgeons, for example, who are admitted only by examination. But they have all frequently undermined and betrayed medicine and threatened the standards of care offered within the NHS.

These organisations protect doctors and not patients. They prefer secrecy to openness and remain largely unaccountable. It is they who have allowed the conditions for dangerous doctors to flourish. There is ample evidence to prove that these institutions have traded on the public's trust for far too long.

Frank Dobson, Health Secretary, has recognised the the problem. Last week he called doctors to account by announcing that hospitals will have to publish the results of their care. "Providing this information, so patients know the risks, is a prerequisite for patients to exercise their common-law right to give informed consent," he said.

Perhaps the most worrying example of indifference to patients is to be found in the attitude of some doctors' leaders to sexual misconduct by their colleagues. I asked Dr Sandy Macara, chairman of the BMA's governing council, whether it was right that doctors who were struck off for sexual offences should be allowed back to practise only a few months later. He replied with the startling observation that "patients tend not to complain about a doctor exploiting them sexually until they [the doctors] stop". He believes that this is "a matter of fact". The solution seems to be that if a doctor wants to avoid being caught for a sex crime, he should carry on exploiting his patient. "That's, if you like, almost the implication," says Dr Macara, although he was keen to add that this is not a practice he would recommend. Rather, doctors should "make a clean breast of it, and make it clear that you're anxious to explain why you made this mistake".

Sir Donald Irvine, president of the GMC, strongly disagrees with Dr Macara's view: "It's a very delicate business," he admits, "but it has to be confronted, it has to be dealt with, because sexual exploitation by doctors is something up with which we will not put."

The BMA has had an unfortunate history of getting it wrong when it matters most. It resisted every attempt by Aneurin Bevan, for example, to introduce the NHS in 1948. The BMA was anxious to protect a doctor's freedom to earn as much as possible. Bevan threatened that autonomy by proposing a salaried medical service. The BMA eventually lost its fight to kill the NHS but only after Bevan amended his plans to preserve doctors' earning powers. The same policy of protection exists today.

The BMA is known among doctors as the British Misery Association. It sees its role as perpetually painting how badly doctors are treated. When doctors were awarded a staged pay increase earlier this year, Dr Macara described it as "a disgraceful betrayal of trust", despite the fact that doctors are some of the best-paid people in the country. He claims that "doctors feel cheated, they feel diminished ... we were initially compared with, frankly, other high earners, because the training, the responsibility, was seen as, at least, the equivalent to those of barristers and of actuaries". Dr Macara - who picked up a knighthood yesterday - thinks doctors have lost their prestige, and it hurts. "Now we're to be compared with personnel directors, with computer operators, and so on."

This reflex carping by the BMA is prompting a backlash among some doctors. In a recent letter to the British Medical Journal, one surgeon argued that doctors "should beware of asking too much. No doctor in employment is poor". Indeed, Mr Dobson plans to crack down on the increasing number of doctors who use their NHS

positions as a platform for doing more lucrative private practice. It is hard to take the BMA's complaints seriously when its accounts show that in 1997 it made a profit of more than pounds 4m, raising its value to a far from destitute pounds 47m.

Medicine operates like an old boys' network. Dr Macara thinks this a good thing. "The old boys' clubs have their positive characteristics," he told me. But only last week, an argument broke out on the letters page of the Times about the inflexible working arrangements for women trying to be surgeons. This debate was sparked by the resignation of one female surgical trainee who felt "threatened" by her male colleagues.

The leaders of the profession - the presidents of the colleges, for instance - exert enormous influence. But the system of patronage in medicine nourishes a malignant conservatism which trickles down through the ranks.

Inevitably, these presidents and their institutions foster a feeling of clubbable security which preserves the status quo. In a welcome flash of honesty, the new president of the Royal College of Physicians, Professor George Alberti, bemoaned the "monotonous regularity" with which he had to wear black tie to stuffy college dinners. He even felt compelled to tell the fellows of his college, which was founded in 1518, that "it is not a London club for retired gentlefolk".

But behind the scenes, the royal colleges revel in their reputations as oak-panelled emporiums for the medical elite. And with justification. They largely control the way the NHS cares for patients. Dr Macara told me that one of the ways he tries to influence Mr Dobson is "over rather an enjoyable dinner, not an excessive thing, but a decent meal over which we can meet and talk and share our thoughts". These informal lobbying efforts are matched by more formal meetings between the profession and government.

A group called the "Top Nine", first established by Virginia Bottomley, advises government about health issues. It includes nine leading members of the profession. When I asked Dr Macara if patients were ever represented on these meetings, he said flatly "No. It wouldn't help". But the problems medicine is facing have arisen because of a breakdown in trust between doctors and their patients. It seems incredible that health service planning can take place without more participation between doctors and patients with ministers.

The lack of trust that doctors put in public opinion is shown most vividly by the secret way in which important reports about health concerns are produced by the colleges. The Royal College of Physicians, for example, is often asked by government to advise on matters of health and health care. It does so by creating working parties that invite evidence to be heard behind closed doors.

The subjects of inquiries have included topical issues such as chronic fatigue syndrome. One of the most contentious matters before the college is the question of how to manage patients chronically exposed to organophosphate sheep dips. Many people exposed to these dips complain of profound long- lasting side-effects. But there is disagreement among scientists about whether sheep dip does cause illness.

In the US, the usual way to investigate controversial health matters is to hold a public inquiry, at which experts gather evidence from witnesses on the public record. Their deliberations are open to scrutiny. This openness makes all the participants in the inquiry accountable for what they say and do and it reveals precisely how decisions are arrived at.

When representatives of patients allegedly harmed by sheep dip asked for a public meeting of the college committee, they were denied it on the grounds that it was not "the best way forward". Despite the fact that patients and doctors alike have called for these inquiries to be made public, Professor Alberti claimed that "I haven't thought about it". To be fair, he understands the concern. He admits that "I'm not convinced that they have to be in secret". He says he "will think about it".

The stench of arrogance that taints medicine owes much to the complacency and self-satisfaction that pervades the royal colleges and BMA. One has only to walk through the marbled luxury of these institutions to realise how out of touch they are with the beleaguered NHS. They seem vacuum-sealed from the realities of lengthening waiting lists, cancelled operations, crumbling hospitals, and patients on trolleys lined up in overworked casualty departments. The leaders of these organisations snipe at government and each other as if they are playing a game.

When I asked Professor Alberti if he feared that Labour's plan to create a primary-care-led NHS would produce a war between the colleges to see who is the most powerful, he said: "I think that's a gross overstatement. I mean we have always been the best. We will remain so." Dr Macara retorted: "George would say that. If George Alberti were chairman of the council of the BMA, he would say that he saw the BMA as being the most important single body - because it is!" Nice banter, perhaps, but somewhat Neroesque in its implications.

All of which makes me very pessimistic about the reaction of medicine's institutions to the Bristol case. The Mirror headline the day after the verdict was delivered was "Doctors of death". The paper reported that "they killed 29 babies and brain-damaged four others by their incredible incompetence". That sort of damning coverage should shock the profession out of its prolonged self-imposed stupor. But the danger is that the Bristol case will be regarded as something peculiar to the technical complexities of cardiac surgery. That conclusion would be a grave error.

The hearing raised two vital issues that apply to every aspect of medicine. First, is your doctor being honest with you? In Bristol lies were told about the success rates of operations being performed. But do you know whether your GP or hospital doctor has a good track record for treating your illness or not? The most likely answer is no. Yet you should.

It has taken Bristol and its effect on government to create the pressure to force publication of this information. The colleges have failed to realise the need to be more accountable. They have sat by and watched as their inaction has been exposed. The BMA's response was to pour a bucket of cold water on the idea of greater accountability. A spokesman argued that it would "create a scare".

Second, can your doctor be trusted? Trust lies at the heart of the doctor- patient relationship and yet Bristol revealed that inexperienced and incompetent surgeons were allowed to operate freely on children. This news came as no surprise. A confidential inquiry into surgical deaths completed in 1996 showed that 76 people died shortly after surgery took place whose operations were done by very junior trainee surgeons. The authors of the report concluded that their evidence showed "sub-optimal standards of delivery of care", including, "inappropriate grades of surgeon (too junior)" and "inappropriate operations".

The profession has known about its failures for a long time. Its response has been denial. When I asked Professor Rodney Sweetnam, president of the Royal College of Surgeons, what his reaction was to the surgeon I saw cut a patient's ureter on purpose, he simply told me that he didn't believe it - three times.

What this evidence shows, I think, is the complete absence of leadership in medicine. There is one glimmer of hope for the future and it comes from a place that has itself come under much fire. The president of the General Medical Council sits in an unusual position. He is very much part of the medical establishment, but he also listens to hundreds of complaints made by patients against doctors.

The number of incidents of alleged misconduct by doctors is rising rapidly. In 1997 it stood at 2,687, 21 per cent up on 1996. In Sir Donald Irvine's recently published guidelines on good medical practice, which came out before the Bristol decision was announced, he called on doctors to investigate carefully how successful their practice really was and to change what they do according to their findings.

Sir Donald also emphasised that "patients have a right to expect that doctors will explain things to them fully and honestly". He is a refreshing voice. He admits that medicine seems to be "unco-ordinated". He sees the GMC taking on the responsibility "to pull the threads together ... to be able to satisfy parliament and the public".

But can we rely on Sir Donald Irvine alone? Based on their track record, it is unlikely that these institutions are going to change because of one person. It is going to take the public to turn them around. Part of the difficulty is that we are all made to feel grateful that there is an NHS. The message is that we should be thankful for what we have got and we should not complain. But it is up to all of us to demand that these institutions listen a little more. That is one of the few positive lessons to come out of the tragedy that took place in Bristol.

`The Citadel', Richard Horton's programme about the medical establishment, goes out this Thursday on Channel 4 at 11pm.

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