Thursday, 31 March 2011

Your Life In Their Hands - Guest Post

I asked Clarinda, a reader who has a comprehensive knowledge of the NHS, if she would be kind enough to respond to this article in the Herald. My sincere thanks Clarinda.

Is there a threshold of warnings to pass before government or management takes serious note of doctors long-running concerns over their education and training? This concern refers to future generations of doctors throughout their medical career with specific reference to Junior Doctors (“trainee consultants”) in their specialist training progammes.  The Scottish Health Secretary has a much better track record of listening to our Scottish NHS concerns than those of her southern counterpart. So, in the light of the upcoming election in May this may be a good time for the medical professionals to make their case clear and expect definitive action. 

Patients are actively encouraged to complain about treatment and care and almost immediately an entire apparatus automatically swings into action to investigate the frivolous from the legitimate – and rightly so.  Why, therefore, as reported – yet again – in The Herald 30:03:11 are the Royal College of Physicians of Edinburgh (RCPE) making their concerns public – yet again?  Are the evidence-based concerns of the most senior physicians not to be held in comparable regard, and action taken similar to that of patients who complain?  Reaction to patients complaints without relevant pro-action on the concerns of their doctors serves to prolong medical risk with financial costs to the detriment of NHS spending on improving patient care… a tragic and often fatal false economy perhaps?

Embedded within Scots Law is the ‘duty of care’; within general medical codes are criteria for excellence in professional practice and ethical behaviour; within specific medical specialist colleges – regulations and standards and no doubt within doctors contracts of employment – duties and accountability.  Along with countless individual hospital protocols and EU directives it is hardly surprising that the doctors are deeply concerned that their training and employment is being undermined by a variety of constant ‘modernisation’ and change which may perversely prevent them from adhering to their legal and professional codes of medical education and practice.

Have we as patients or potential patients (this includes doctors and nurses!) become so accustomed to being unsurprised by lower standards than we would expect, with ever more simplified access to making a complaint and obtain compensation, chosen to ignore the more subtle growing risks of inadequately prepared Junior Doctors as indicated by the President and Chairwoman of the RCPE.  We are losing a high number of new medical graduates who either leave the profession altogether or the country to seek the clinical experience, so difficult to obtain here as Junior Doctors, prior to specialist (consultant) training. A member of my family is one of those hundreds of young doctors gaining valuable experience abroad after his two Foundation Year training programmes and who may or may not return to this country to embark on his specialist training.  He and his other medical colleagues were encouraged by senior doctors in this country to gain experience elsewhere to augment their potential and be in a much better position to make a quality judgement and choice of which future specialist career pathway they want to pursue.  Junior Doctors are now expected to make premature career choices and once started cannot be changed unless starting the process again.  Specialist training now takes only five years compared with the previous ten plus years before becoming consultant material.

The European Working Time Directive has catapulted the already questionable changes to medical education and practice into sharp profile but perhaps only the doctors themselves are aware of the real subtlety and potential dangers for their current and future practice and ultimately - patient safety. Mistakenly, their concerns are put down to scare mongering and shroud waving – but is our health worth ignoring until it’s too late?  It’s long past time that we listened to what the doctors are saying – but not through the vested interest filters of politics, NHS management or the MSM.  In Scotland we have a good grasp through our Health Secretary – but there is plenty room for improvement.  Good health is precious and our doctors want to keep it that way.



WitteringsfromWitney said...

SR: Funny this should appear this evening........

Today I left home at 2:30 to take a neighbour who cannot drive to the Churchill hospital in Oxford for an appt at the haemotology ?) dept. Arriving at 3:10 he was eventually weighed (why?) at 4:20. He eventually was called in by a doctor at 5:45 and we arrived back here at 7:30.

The reason? EWTD meaning they had a shortage of doctors!

The sooner we get out of the EU, privatise the NHS the better! Having experienced BUPA, believe me it is a world apart, you get seen on time etc etc......

Oldrightie said...

Above all else, professions ought to be run by professionals.Sadly politically motivated "managers" are the norm.

hector said...
This comment has been removed by the author.
hector said...

the ewtd ensures that junior doctors are working reasonable is not that long ago when junior doctors were working 60-70 hours plus in a week. was that good practice?we had ?10 years warning re the ewtd.if there is a shortage of doctors we should we be training france for example i understand there are more doctors per head of population than in the do the french manage?

subrosa said...

It's not for me to respond to you all as this is Clarinda's post and she will, but I've something to say to hector.

Many of the military work 60-70 hours a week without complaint. Many of those are also involved in saving lives and protecting others.

As I see it the doctors weren't complaining about working these hours because they knew they gained more experience. Now many join the TA because they want to know how they will work under pressure and cope with fatigue.

What would happen if we had a national health scare with this new directive?

Why should we train more doctors only for them to be snapped up by English speaking countries such as Canada, the US, Australia and NZ because they all know our training is the best.

The EWTD is stifling talent.

Clarinda said...

WfW - this is what I meant about what doctors are required to practice by law and professional codes yet barred by bureaucratic rulings designed to stop blatant exploitation of workers not the vital practice and learning experience of professionals and increase the risk or inconvenience to patients. Managers have been warned that this inadequate medical staffing would be an issue and I hope you informed them of your delay.

Clarinda said...

OR - we need good managers in the NHS but not necessarily holding ultimate power and certainly not in the eye-watering numbers we currently employ. We must be wary in the huge NHS organisation that we tie up too many expert clinicians in managerial roles instead of being decision-makers with a streamlined management implementing the system and process of achieving that clinical excellence. It may be better to remove the NHS from political flux and also not be adverse to learn efficiency and effectiveness lessons from established private health care systems.

Clarinda said...

Hector - I agree that over long hours could be dangerous - but doctors attempting to cram too much work into shortened times, as is currently common, is equally if not more dangerous? There is a balance to be struck between what is a reasonable workload to be safely and competently achieved within a reasonable time scale. The inevitable problem is that patients are naturally unpredictable with uncertain, unstable and complex needs that defy the clock.
It's not just daily hours that are being questioned but the total hours over a five year period now prescribed for consultant training in comparison with what was a longer and more flexible training schedule a few years ago.
Interestingly, as I tried to describe, substantial numbers of our expensively trained Junior Doctors, Registered Nurses, Midwives and other Health Care Professionals leave the UK in their hundreds every year to gain work experience unavailable here due to a mixture of EWTDs and other managerial work restrictions!
Perhaps if we had clinicians back in ultimate decision-making roles this could be significantly reversed?
I am not fully aware of the systems in France but even with a much smaller population, the UK NHS is something like the 3rd largest employer in the world just behind the Chinese Army and the Indian Railway so I'm told - which makes me wonder if France has got it's health care management system in much better order.
You have a valid point in training greater numbers - but that is costly and we are leaking our current doctors through the unattractive NHS management system. Plug the reason for the leak in the first place and then calculate what we are prepared to pay for better doctor patient ratios!

hector said...

Clarinda-it would be interesting to see how other e.u. countries are dealing with the do they manage their services?what do they pay their doctors?how much do they spend on health care?re staff moving abroad.doctors and nurses have always moved around to gain experience.just as doctors and nures from other countries come here to work.bringing
ultimate decision making back to health professionals may help.however care should be taken that no one profession becomes dominant in this.

hector said...

Subrosa-a bit sneaky bringing in the military.not quite comparing like for like for like for obvious reasons.
in the case of a health scare i am sure exceptions would be made, as they are at present.recently lorry drivers hours were extended to deal severe weather conditions.

subrosa said...

Sneaky hector? Mmm. There are medics in the military you know. Who do you think cares for those a Camp Bastion hospital for example and also the Queen Elizabeth in Birmingham?

Why isn't it comparing like with like? Trauma is trauma whether it's a car crash or a shooting by an 'enemy'.

My point is the EU directive isn't implemented in the military yet their medics don't seem to be complaining in any way. In fact these days many are civilian doctors/nurses who volunteer through the TA because they want the experience which they're now finding hard to get in civilian situations.

Clarinda said...

Hector - I have written a reply to your comment twice but my google account has a fault and they've disappeared but I will try again - let's hope this gets through!

Crinkly & Ragged Arsed Philosophers said...

The EU has an answer to everything and a solution for nothing.

As such, and in respect to the issue under discussion, they fail to understand the difference between job and vocation.

And why would they, when their experience and claimed expertise is moulded in the soft 'science'
of the political and bureaucratic quagmires.

Which is why, in the case of the NHS, ethos such as privatisation and management take priority over those of the clinicians.

In effect, we now have storeman deciding the production rate, product quality, working conditions and methodology, development, book values and profit centres of a commercial enterprise.

For some reason I don't think that was quite what the pioneers of the NHS had in mind, nor do think the logic would be acceptable to a business manufacturing widgets. So what exactly is their purpose behind this hybrid mutant philosophy they're forcing on the NHS?

Clarinda said...

Hector - third time lucky I hope!

Good questions - I have it on pretty good anecdotal evidence that EU doctors and many others base their working practice on what's right and proper according to their professional codes of practice rather than the rules etc. that hamstring UK working practices.

Yes, our doctors etc. have always gone abroad but never in such numbers with many failing to return leaving enormous gaps in medical cover here worsened by the dreaded EWTD.

I don't have too much of a problem with a "dominant" profession in charge, as long as it is effective, but perhaps the trick is to follow a successful organisational health model used in other countries where the clinicians are on fixed term decision-making and managerial appointments working closely and often in charge of a streamlined management system.

Some time ago the late Sir John Harvey Jones and more recently, Gerry Robinson, both top end management gurus, independently found the UK NHS management almost laughable in its refusal to embrace the potential of health care professionals in full decision-making roles rather than their marginal advisory roles.

We need to look carefully at why we need so many from abroad to cope with gaps where we may be needlessly losing our own expensively trained staff. Our doctors are well paid in comparison with many of those in the EU so we are not talking the profession demanding personal money but the eye-watering amounts spent on managerial kite-flying and poorly researched 'modernisation' must be more efficiently targeted.

The politicians must start acting on the deep evidence-based concerns of professional colleges etc. and less thinking that management, and politicians, have all the answers. Keep healthy!

Clarinda said...

Mr Crinkly - spot on! It's right that hours are not used to exploit workers but not to the point where profesional vocational attributes - as you rightly point out - are not jeopardised.

There is a sense that medics were seen as elitist and needed to be brought to heel. Certainly the vocational aspect still reigns strong but up against an antagonistic hierarchy of politically generated management the quality of goodwill, commitment and loyality is at a dangerous premium. Most doctors now can't wait to retire at 60 or less - not because they are tired of patient care but dog-tired of the suffocating system.

Crinkly & Ragged Arsed Philosophers said...

Clarinda- hegemony's have always nurtured their incompetence behind the guise of necessities, which, when fully considered are not necessities at all but self blandishing vanities.

The matriarchal side of my family is one of Matrons stretching from Buckie to London - were they able to rise from the grave the ire of their damnation would have many an ear burning red.

From the context of your post, it is the 'sense' that's sorely needed; more power to your elbow.

hector said...
This comment has been removed by the author.
hector said...

clarinda-i agree with many of your points.the ewtd has possibly shown up
elements of junior doctors hours and trainig that need to be'nt know if you need to be exhausted from working long hours to gain experience.

hector said...

subrosa-yes the military has also is not subject to civilian law,it workforce are trained to shoot and it is pretty difficult to question your it has to be, as conflict requires different rules from everyday life.

subrosa said...

You have a very narrow view of the skills within the military hector when you see them only as trained killers. I doubt if I could change your mind so I won't bother, except suffice to say our military has some of the best engineers and technicians in the country. Many of them produce work which is used in civilian life. Not all are doing target practice every day of the year.

Unfortunately yes, they're not subject to civilian law. They're not even protected by the HRA when out of the UK.

hector said...

subrosa-i have a broad view and admiration of the military and what they have to do.i was trying to make the point it is difficult to compare it to the workings of the n.h.s.i can only apologize for any misunderstanding.

subrosa said...

Perhaps if we look at it from the other perspective hector, we would find that the NHS would be far more efficient if they took a leaf out of the military's book.

That's what many TA medics say and why they join up - to see how they could work without the unnecessary management from which the NHS suffers.

Hector, there's no need to apologise for your opinion. I always respect the views of others and enjoy discussion. Thanks.

Jo G said...

I have a relative who has MS and I have seen how the Scottish NHS has treated him. He has MS and therefore......

It makes me furious. I could write a book about how the NHS in Scotland has failed him at every level because patients with MS don't matter. They're ill anyway. I could say more here but I shall not because it would breach his right to privacy. But I have seen it with my own eyes. It is disgraceful.

Jo G said...

"The matriarchal side of my family is one of Matrons stretching from Buckie to London - were they able to rise from the grave the ire of their damnation would have many an ear burning red."

An ear Crinkly? I think there would be a few sore erses also.

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