An ordinary day at an ordinary hospital outpatient clinic. Men and women, mostly women, are waiting to see the specialist. They have taken care with their appearance. They want to make a good impression. There is the usual whiff of anxiety in the air.

Now it is the turn of a woman seeking treatment for her varicose veins. The consultant smiles, reads her notes. All is routine, well ordered. Then something very unusual happens. The women looks the specialist in the eye and does the unthinkable. She questions his competence. 'What do you know about varicose veins?' she asks.

John Spiers would have been delighted with her nerve, had he been a fly on the consulting-room wall. He has been promoting patient power for three years, first as chairman of Brighton Health Authority and then, increasingly loudly, as chairman of the Brighton Health Care NHS Trust - until three days ago.

On Monday night the standing consultants' committee passed a vote of no confidence in their chairman. Sixty-five senior hospital doctors were united in their opinion. There were two abstentions. Without the full support of the trust's board, in the face of this unprecedented conflict, Mr Spiers resigned.

It is the first time that a body of hospital consultants has ousted a trust chairman, and it is sending ripples of alarm through health service management circles. This is really about the struggle for the new National Health Service, a battle being fought between a hitherto all-powerful medical establishment which wants to steady the pace, and the new breed of managers grafted in by a government bent on changing the culture.

Mr Spiers - champion of NHS changes, of patients and of Virginia Bottomley - has, frankly, been asking for it. But he cannot have anticipated this outcome. He has strong Conservative Party credentials, friends at Number 10, and in June he was appointed to the Prime Minister's Citizen's Charter Advisory Group, from which he has also resigned. Perhaps he thought he was bomb-proof.

His style could not have been more flamboyant. This is the man who, in order to test his motto 'Putting Patients First', took himself, incognito, in a wheelchair into the accident and emergency department of the Royal Sussex County Hospital, pretending to have lost all feeling in his legs.

He found little to his liking. He was warned of a five-hour wait; he was sworn at by a porter; he was told that he would have to wait 20 minutes for nurses to take him to a disabled toilet on another floor. And he saw to it that it was a well-publicised event.

In a second adventure, he put on distorting spectacles to test the

reception at the Sussex Eye Hospital. He was told, wrongly, that the named ward he asked for did not exist, and then crossed a busy main road to look for it in what he said was the most terrifying 30 minutes of his life. He experienced, he reported, the 'invisible hospital' that managers never saw. Patient services improved.

Hospital staff were appalled. This was sneaky, and not how a chairman is supposed to behave. But their discomfort was nothing compared to the outrage that Mr Spiers has inspired among senior medical staff in his power battle with

the doctors.

The public reason for this week's no-confidence vote was an article published in the British Medical Association's News Review in July. In it Mr Spiers described doctors as 'meddlesome' and 'dangerous'.

Here is a flavour of what he wrote. On breast cancer and the need for a highly specialised service: 'If you are going to a bog standard meddler you are likely to die. We are killing thousands of women who should be alive.' On doctors whose standards of medicine are below par: 'The dangerous and alienated doctors need to be mentored and retrained.' And, surely tongue in cheek, he continued: 'It would be a great pity if some doctors make themselves unemployable.' He says he is not surprised that medical staff found his article a bitter pill to swallow. Had he not warned them that they were now in a new world?

But the remark that lit the now well-laid

fuse was this: 'Some (consultants) are among

the most subtle, intricate minds I have ever met. Some of them I would not choose to travel

in a railway carriage with.' So on Monday night they bought their chairman a one-way ticket out of town.

The division of opinions on the merits and faults of John Spiers is scalpel sharp. On the management side, friends and colleagues describe him as Renaissance Man - honourable, thoughtful, imaginative, dynamic. Doctors describe his support of Mrs Bottomley as sickening. They call him confrontational, insensitive, self-interested.

Mr Spiers is 52, divorced, and a multimillionaire publisher and consultant. He began his own business with capital of pounds 300, and eventually sold it to Simon & Schuster. He is a collector of

20th-century art and established a trust to bring art to the walls of Brighton's hospitals. He appointed the first patient advocate

in an NHS trust. One of his patient leaflets announced: 'We want to spend pounds 100m on you.' The bedrock of his beliefs is that the health service belongs to

the patients and not to the

medical establishment.

Doctors in Brighton feel insulted by his pronouncements. In fairness, as a body, in pre-trust days, they were among the first to take on the ideas of clinical audit - the long overdue system by which they monitor their own performance and set standards by which to measure 'patient outcomes' or the success of treatments. Although at pains to say that they support the aims of the trust itself, they saw Mr Spiers's future and they did not like it one bit. They are also frustrated and disappointed that there are no plans to build a new hospital on a greenfield site, in an area whose hospital buildings are mostly Victorian.

In common with colleagues in the rest of the country, they feel overworked and threatened by the Government's intention to impose a system of locally determined performance-related pay, which the BMA is fighting. All of this has fuelled the row.

The gloves came off this spring when Mr Spiers instituted a Clinical Performance Unit to measure doctors' standards of work and, ultimately, link them to pay. At about the same time, in a speech to the Royal Society of Medicine, he developed his theme of a medical 'secret garden' where mystery prospers alongside power without accountability. He quoted from the Frances Hodgson Burnett novel: 'It's the garden no one can go into. It's the garden with a door. How I wish I could see what it's like.'

He said that measuring patient outcome was not enough, and suggested real

patient power. 'Let's go into real choice. Let's say to patients: 'You can have an operation and while we have two consultants who may not do it the same way we can

give you their records.' Ordinary people want to know who are the good surgeons.'

The NHS market, he said, 'should be actively retiring the older ones who obstruct the march forward, and exerting pressure to change the younger ones who have old attitudes.' He promoted the idea of 'walk-in' clinics to which patients referred themselves - revolutionary stuff from a doctor's viewpoint. There was a great deal more on similar lines.

But in the end it was too much, too soon. The Department of Health, uneasy over the national conflict with consultants about pay, distanced itself from its most colourful supporter. In a formal statement it said only that Mr Spiers was 'lively' and that the affair was a matter for the trust. There were no public statements of regret. The anxiety now is that other consultants, inspired by the Brighton operation, will attempt similar surgery of their own.

Some say this would wound the NHS reforms so deeply there would be little chance of recovery. Ironically, if chairmen of health authorities were elected by the populations they serve, and not appointed by the Secretary of State, John Spiers might well be in his post today.

(Photograph omitted)