The National Health Service may be far more sickly than we think

`The Bristol inquiry may ratchet up the claim for extra funds for the NHS in a dramatic fashion'

FEW THINGS - rightly - get us quite as excited as the issue of trust in the medical profession. The public inquiry into the activities of some surgeons at Bristol Royal Infirmary (BRI) is about to enter its high-octane stage. This will be about more than just the careers of one or two medics; it will be an unparalleled examination of the real state of the NHS.

Over the next six weeks the key players in the tragedy that led to the deaths of too many babies undergoing heart surgery at Bristol will give their account of the events that have convulsed the medical establishment - in many cases for the first time.

The inquiry has held more than 70 days of public hearings. Hundreds of hours of testimony have been given by witnesses, including accounts from the parents of babies who died, and millions of pages of documents have been accumulated. It is the biggest medical inquiry yet held in Britain, and although it is about to reach an emotional climax, at least one watershed, which gives a clue to the outcome, may already have passed.

Between now and 16 December, when phase one of the inquiry ends, James Wisheart and Janardan Dhasmana, the disgraced surgeons at the centre of the tragedy, will take the witness stand in turn, breaking their self- imposed silence since the General Medical Council found them guilty of serious professional misconduct last year. Mr Wisheart, a cardiac surgeon with an international reputation and a merit award that doubled his NHS salary, was struck off the medical register; Mr Dhasmana, his consultant colleague, was banned from operating on children for three years and was later sacked by the BRI.

The two surgeons are certain to attract intense media attention. Mr Wisheart, a man not plagued by self-doubt, who maintained a studied aloofness from the GMC proceedings last year, is likely to present a vigorous defence of his role. Mr Dhasmana, who was less certain of his skills and at one point sought retraining in Birmingham, may admit some failings. The spotlight will also fall on John Roylance, chief executive of the infirmary, who was struck off the register for his part in the tragedy. The three doctors were found guilty by the GMC of allowing the complex heart operations to continue long after they should have known that death rates were too high. One further key player is also expected to make an appearance: Stephen Bolsin, the whistleblower credited with raising the alarm, has agreed to return from Australia, where he now works.

But while the focus over the coming weeks is likely to be on the surgeons and the whistleblower, it looks increasingly as though the real story lies elsewhere, and will await phase two, when the panel will look at the wider lessons from this case.

An indication of the way this will go emerged in pivotal evidence presented to the inquiry last week. A detailed statistical analysis of Bristol's performance compared with that of the 11 other specialist paediatric cardiac surgery centres around the country showed that its death rate was twice the average. This finding was instantly seized on as confirmatory evidence of the poor quality of surgery at the infirmary.

The next day's evidence, however, cast it in a different light. In addition to the statistical analysis, the inquiry commissioned experts to carry out a detailed clinical review of 80 randomly selected cases from among more than 1,800 treated at BRI between 1984 and 1995, to provide a picture of the standard of care. Each case involved a total of 15 hours' work by five different consultants, who assessed care under a dozen different headings, from diagnosis through surgery to aftercare.

The most striking finding was that of the 100 operations performed (some children had more than one), in only two cases did the expert assessors conclude that better surgery would probably have led to a better outcome. In seven more cases, better surgery might possible have led to a better outcome. Yet, overall, the clinical review found that half the cases received inadequate care and in 30 per cent - almost one in three - better care might have led to a better result.

The inescapable conclusion is that the problems at Bristol involved much more than the skill of the two surgeons. The clinical review highlighted, in particular, difficulties with diagnosis, poor initial care and delays in getting the children treatment. Poor standards in intensive care, difficulties with communication among members of the team and shortage of resources were also revealed.

The evidence thus points not to a couple of rogue surgeons, but to a wider institutional failure, for which they may have been made scapegoats. This is a much greater worry for the NHS. For whereas rogue surgeons can be dealt with simply by striking them off the medical register, a system failure in the NHS is going to be much harder - and much more expensive - to deal with. There is alarming evidence from America that lends weight to this. Research conducted at Harvard University, when extrapolated to the UK, suggests that system failure may be responsible for 30,000 deaths a year - equivalent to two jumbo jet loads a week.

If hospitals are killing patients at anything like this rate, then urgent corrective action is needed. Set against the demands for a pounds 2bn investment in the railways following the Paddington disaster, the Bristol inquiry may ratchet up the NHS's claim for extra funds in a dramatic fashion. Management is almost certain to be identified as a crucial weakness. Another issue will be the fragmentation of care as a result of increasing specialisation. Yet another will be resources.

In the course of the inquiry, members of the panel visited Ward Five at the BRI, where many of the events under scrutiny took place. It is now an adult ward (paediatric cardiac surgery has been moved to the Bristol Children's Hospital under a new surgeon, where its success rate is among the best in the country). Ward Five is a grim place, of the sort you might expect in Eastern Europe, according to some. It would take much to put right.

Professor Kennedy stressed at the start of the inquiry that it would be non-adversarial, and that there would be no winners or losers. When it concludes late next year, however, there may be one; the Treasury could turn out to be a heavy loser indeed.