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Failure in Self Regulation of the Medical Profession


In most cases, the public is not very much informed when it comes to acquiring specialist services provided by professionals and as a result, they may be exposed to the risk of accessing substandard services because they cannot differentiate between a competent professional and an inept one. Professional regulation is a general operation by the government but self-regulation is also possible and has prevented the free market from exploding with incompetent experts. However, self-regulation can only create a cartel of few service experts. This can only be tolerated as long as it’s in the public’s interest, to protect their abuse, and make sure that the services provided are excellent. Failing to restrict the scope of practice, setting standards for entry and providing ongoing quality control becomes an issue of discussion. Therefore this paper presents an example of failed professional; control and the lesson learned from it.

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The Bristol Case as Failed Self Regulation

The Bristol case of 1995 was an eye-opener for the government and the unsuspecting citizens of the amount of danger that professionals entrusted with saving a life could do. This was a very big abuse of collegiality in the pediatric heart surgery that was done at the Bristol infirmary [1]. However, the case was very beneficial to some extent since it is from this that the end of the Laissez-faire model of safety to patients was ensured [2]. Self-regulation and the management and evaluation of clinical service quality were restructured.

The Bristol Royal infirmary is a very important healthcare facility in Britain since it has been offering very important services to the patient especially heart problems [1,3]. Basically, if there was no treatment at Bristol, then the viewpoint could be miserable. Some patients could even suffer beyond assistance. Nonetheless, over the past years, treatment was made possible for any condition at the facility especially surgery [2]. This was the one type of surgery that was especially very critical, the open heart surgery [18].

As the institution was getting more successful, some problems emerged. In the 1980s, there were concerns that started being raised, about the competence of the workers at Bristol. The atmosphere and the people who needed and used the services of Bristol were characterized by doubts and concerns about the element of the performance of the practitioners [1,2]. These concerns increased considerably and they got to the media. One major surgery became the catalyst to the reaction from the public. One Joshua Loveday was taken ill to the hospital for a cardiac problem. He was set for surgery on 12th January of 1995 [2]. Unfortunately, Loveday did not make it through but rather died on the surgery table. Following that incident, there were other twelve complaints that were forwarded to the General Medical Council (GMC). Two practitioners were accused of malpractice; Mr. Janardan Dhasmana and Mr. James Wisheart who were very crucial practicing surgeons and their Trust Boss Dr. John Roylance. The three practitioners were found Guilty of malpractice [2,4].

Over the past years and until the recent past, the GMC was the only regulatory body that controlled the nursing profession [1]. In medical care [5], the practitioners have a responsibility rather than a statutory duty that makes them responsible for protecting the public in their professional capacity whether in practice or not [1,2]. However, the case at Bristol was a breach of this law. Their healthcare conditions were deteriorating and the professionals were making mistakes that they were not telling their patients. The duty number one of a medical practitioner is to his/her patient [1]. Therefore if anything goes wrong while attending to the patient, the doctor has to explain to the patient what happened and suggest means of correcting the problem rather than keeping quiet over it [3,6].

In Bristol, the deaths from surgery were considerably high and the hospital was aware of it. It is presumed that the switch artery and repair technology had become complex for Mr. Wisheart and Mr. Dhasmana. Mr. Dhasmana had even when to Birmingham to train on the switch arterial technology but this was achieved as it proved very difficult for him [2]. Basically, if a practitioner cannot perform a certain duty and especially when it is consistent with the survival of an individual, there is nothing better than stopping that person from practice [1]. However, for these two doctors that were not done and they continued with practice [6].

The self-regulation Body, GMC should have taken the initiative of living up to its objectives which were to set standards and certify workers. This should have of course been followed by constant monitoring of the performance [4]. The death rates in Bristol were considerably higher than in other facility meaning that definitely something was wrong [4]. Furthermore, the trend had been taking place for years. In tort law, this is the negligence of duty.

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Duty- the liability here is not mainly due to the outcomes of intentional damage to the patient. Negligence was cited, the case should have been treated as a criminal case since the doctors exhibited gross incompetence and acted recklessly basically showing unconcern for the safety of patients [4]. Tort law explains this as a breach of an obligation to act with caution [9], or the failure to act as a sensible and layperson would have done under the same conditions [4]. According to Dr. Bolsin, who was also a specialist consultant at the Hospital and the whistleblower, too many infants were dying during the process of cardiac surgery [9]. He tried very much to come up with ways to reduce the mortality rate, sometimes confronting the surgeons to no avail [5,6]. The GMC refused to investigate the surgeon as well [10].

Despite the major clinical reform proposal that was made, BMA refused to recognize the need for transformation [5]. Even when the issues were raised to the GMC after whistle-blowing, the body took the longest means of investigation that cost over 2 million pounds in a span of 8 months [7,11]. It was in fact the longest case in the history of GMC [5]. Even though the case ended up scrapping the three doctors from the list of registered practitioners, it still left many questions of when the medical practitioners could really self-regulate themselves if they could not protect the patients they were supposed to help especially children for that matter [7,8].

Lessons Learnt

There are a lot of lessons that can be learned from the case of failed self-regulation in Bristol [20]. This is because the discipline, license, powers, standards of practice have to be kept in constant watch since they can go wayward at any time [10]. The autonomy of practice cannot be left to so much independence and have so much freedom that British Doctors enjoyed [11,12,13]. This is because it can lead to abuse of power when those in charge fail to act. This is when the concept of collegiality becomes highly abused [20]. By virtue of the patient-nurse relationship, the practitioners owe their clients a duty of care which includes disclosing and explaining to them their shortcomings and suggesting other alternatives [13], keeping their information private, attending to them and offering the necessary and relevant type of service the patients want. Breach of these could result in the offense of negligence which is law enforceable [14,15]. The use of professional knowledge and skills in the medical profession is a must since failure to do so is considered act negligence. This is punishable by law [16,17]. Another major lesson from the Bristol case is to store accurate records [12]. This would help track the doctor who performed certain services on specific patients [17,19]. The concept of self-regulation without a third body to oversee the process, lead to further problems. For that reason, the government takes the initiative to regulate the practice [20].


Self-regulation should enhance autonomy and best practice at the same time. However, that was not the case in Bristol. These justifications suppose a largely unselfish state concerned with regulation to safeguard consumers; there are no selfish interests on the part of the state. In the medical profession, self-regulation means that practitioners have an independent body that offers self restrictions and standards of operations. The problem is that self-regulation has faced issues concerning its integrity and in some instances, it has failed to achieve the goals that are intended. This is a letdown of professional self-regulation.

References List

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  2. Allsop J. & Saks M. Regulating the Health Professions. London: Age; 2002.
  3. Barnes N. Very Short Service on the Bristol Inquiry. BMJ 1998; 317: 1577-1579.
  4. De Leval M, Francois K, Bull C, Brawn W & Spiegelhalter. Analysis of a Cluster Of Surgical Failures. Application to a Series of Neonatal Arterial Switch Operations. J Thoracic Cardiovasc Surg 1994; 107: pp. 914–924.
  5. Dyer C. Bristol Doctors Found Guilty Of Serious Professional Misconduct. BMJ 1998; 316:1924.
  6. Dyer, C. Compensation Claims Expected to Follow GMC’s Findings in Bristol Case. BMJ 316:1691.
  7. English A, Bailey A, Dark J, & Williams W. The UK Cardiac Surgical Register 1977-82. BMJ; 1984; 289: 1205–1208.
  8. Faunce T. A & Bolsin S. Three Australian Whistle-Blowing Sagas: Lessons for Internal and External Regulation. Med J Aust 1994; 181: 44-47.
  9. Garrett J, Savage W, & Cain R. The Bristol Affair. BMJ 1998; 317: 1592–1593.
  10. Irvine D. The Performance of Doctors. BMJ 1998; 314:1540.
  11. Klein, R. Competence, Professional Self Regulation, and the Public Interest. BMJ 1998; 316:1740–1742.
  12. Klein R. Competence, Professional Self Regulation, and the Public Interest, British Medical Journal 1998; 316: 1742.
  13. Rosenthal M. M. The Incompetent Doctor: Behind Closed Doors. Buckingham: Open University Press; 1995.
  14. Samanta A & Samanta J. Regulation of the medical profession: fantasy, reality and legality. J R Soc Med 2004; 97(5): 211-218.
  15. Slater B. Medical Regulation and Public Trust: An International Review. London: Kings Fund Publishing; 2000.
  16. Smith R. Regulation of Doctors and the Bristol Inquiry. British Medical Journal 1998c; 317: 1539-1540
  17. Smith R. Regulating” Doctors: What Makes Them Practice As They Do? In: Klein R, Editor. The Quest For Excellence: What Is Good Health Care. London: King’s Fund; 1998b.
  18. Smith R. All Changed, Changed Utterly. BMJ 1998; 316: 1917–1918.
  19. Stacey M. The General Medical Council and Professional Self-Regulation. In D. Gladstone, (Ed.) Regulating Doctors. Institute for the Study of Civil Society.
  20. Treasure T. Recent Advances: Cardiac Surgery. BMJ 1997; 314: 104–107.

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