Then they fell out and for some years they have hardly spoken

Then they fell out and for some years they have hardly spoken. Mr Westaby has gone his own way, and he has never been slow to tell the world about it.Several factors appear to have triggered the deterioration in their relationship - among them the shortage of staff and resources, which meant they were competing for beds and operating time. But one subject surfaces repeatedly on the gossip circuit in Oxford - drink. Ravi Pillai is known to enjoy a drink - as do most surgeons - but there are allegations going back several years that he has been under the influence while on call. Friends say Mr Westaby stopped going to social engagements because he felt he had to cover for his own patients himself, instead of sharing the burden with others.The independent inquiry tiptoes around these issues. But it criticises the trust management for "never properly investigating" a drinking incident involving Mr Pillai in 1997 and for issuing a weak reprimand in a letter for an incident in May 1999, when it was claimed that Mr Pillai had been drinking at a party. "In our opinion this letter failed to spell out the very serious consequence, which was that Oxford potentially had no paediatric cardiac surgeon cover that evening," the inquiry report said.Whatever the cause, the deterioration in the relationship between the two surgeons affected the whole unit.

The annual number of heart operations dropped from 1,400 to 800 in four years, and waiting lists soared. Two surgeons, one of them Mr Pillai, were suspended and later re-instated, training recognition was withdrawn by the Royal College of Surgeons, a nurse who acted as a whistleblower was off sick for a year and there was an exodus of nursing staff, leaving 60 per cent of posts unfilled. It was a unit unquestionably in disarray.Similar charges of feuding consultants are heard with disturbing regularity across the NHS. Derriford Hospital in Plymouth is currently in the grip of a dispute between rival surgeons like that in Oxford. Personal differences and lack of effective management lay at the centre of the Bristol babies heart surgery disaster and figured heavily in the cases of the disgraced gynaecologists Rodney Ledward and Richard Neale, who were both struck off the medical register by the General Medical Council after injuring scores of women.

Hospital managers in the Neale case were at such a loss over how to deal with the rogue surgeon that they finally paid him £100,000 and gave him a good reference to get rid of him.Barry Jackson, president of the Royal College of Surgeons, spoke out last month about the number of "vindictive" allegations made by feuding surgeons that had triggered hospital inquiries. The college's rapid response team, set up to help NHS trusts to defuse problems before they explode, had conducted 30 investigations in 16 months, and in a "significant minority" personality clashes were to blame."Modern surgical practice is all about teamwork I hope the days of the prima donna surgeon are over... a different culture has got to emerge," he said.Some, however, are finding it hard to give up the old culture. Surgeons tend not to be shrinking violets - it is in the nature of the job. A high degree of self-confidence - even arrogance - is an essential pre-requisite for someone capable of slicing people open, rearranging their internal organs and sewing them up again. Surgeons who trained in an era when they knew everything, did everything and relied on no one are only reluctantly relinquishing control.

Their intellectual superiority, higher earnings and the nature of their role in the NHS, combining power without - until recently - accountability, makes them particularly prone to the condition. But in the increasingly complex world of modern medicine, the capacity to work as part of a team is essential to achieving an effective outcome for patients. That is what was missing in Oxford.The inquiry into the Oxford heart centre, ordered by the south-east regional office of the NHS executive, quickly found that the rift between the lead surgeons had become a chasm dividing the entire unit. The inquiry panel adopted the device of starting interviews with staff by asking which side they were on, like football supporters.

It identified a "drinking club culture", a group of friends based around Ravi Pillai who went to the pub after work on a Friday night, and warned of the danger of "cliques" and "cronyism".A crucial question was whether patient safety was affected. When the inquiry report was published, the Oxford regional director of public health, Dr Mike Gill, said, with evident relief: "It is important to recognise the review does not call into question the centre's clinical outcomes."This was not quite the whole picture. Although the published death and complication rates for the centre were good, the inquiry drew attention to the "well-known defects" in the data, because Oxford lacks a computerised system to allow the results to be validated and "risk stratified" (adjusted for the severity of the cases). In addition, a three-year audit of the years 1996 to 1998, passed as satisfactory by the former medical director, Chris Bunch, was challenged by the cardiologists, who decided to concentrate all mitral valve surgery in the hands of two surgeons, Stephen Westaby and David Taggart.