Leading Article: Pride before a scandal

THE bare facts of the scandal in Birmingham are eloquent enough. All the surviving 1,800 patients whose cases were considered by the bone cancer unit during the past eight years are to be re-examined after an inquiry found evidence of persistently inaccurate diagnosis of suspected tumours. Some patients whose tumours were benign were given chemotherapies that actually increased their chances of developing cancers; others were misdiagnosed as suffering from benign conditions. Of these, the inquiry reports that 'inappropriate treatment may have had irreversible consequences'.

What is really frightening about the situation revealed by the inquiry is not the fallibility of the individuals involved. The diagnosis of bone tumours is notoriously difficult even for the best in the field. The rate of failure by the pathologist in Birmingham, Dr Carol Starkie, was unacceptably high, but such things will always happen. People are promoted above their competence in any organisation. The test is how the consequences are dealt with.

It is this test that the authorities in Birmingham failed, with catastrophic results. That failure is the second most shocking aspect of the report; the most shocking is the breathtaking arrogance of the surgeons involved. They complained that the health authority had 'over-reacted' by calling a public inquiry, though they had themselves been aware of inadequacies in the pathology service for five years, and had grumbled privately about them.

The failure and the arrogance are intimately related. Dr Starkie was not failing in a vacuum. On the contrary, it is already recognised that specialists in such a difficult field should collaborate with each other, both within and between hospitals. In Scotland, for example, pathologists who diagnose bone cancer meet every month to examine and comment on each other's specimens and, so far as possible, to reach a consensus on every case. This is a system that recognises the fallibility of all involved. But it is voluntary. Dr Starkie and her colleagues were able to evade peer review for eight years without, apparently, anyone outside Birmingham noticing.

Such failures of self-regulation seem to strengthen the case for the closer control of the health service entailed by the recent Conservative reforms. If the NHS is made more accountable to the patients who are its ultimate customers, then, surely, the arrogance of doctors will be diminished, and they will remember their prime duty is to their patients, not to their colleagues.

Unfortunately, there are worrying signs that exactly the opposite is happening; and that one effect of breaking the NHS into competing parts is to diminish the co-operation between specialists so necessary on the frontiers of medicine. One cause of problems in Birmingham was the demand for quick diagnoses rather than slow and certain ones. This, says the inquiry, 'was motivated more by logistical reasons than by the need for rapid treatment of tumours'. It is not incompetence, but pride and bureaucratic manoeuvring that appear to be the real villains of the story. Their role is a subject that the commission of inquiry should consider closely when it makes its final report.