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Consultant Numbers, Again
55
Commentary Consultant
from Westminster Numbers, Again
ANYONE seeking change for the better in the NHS would do well to study the fate of plans, laid in 1981, to increase NHS consultant numbers and reduce junior hospital posts. The Government, health authorities, all doctors’ representatives, and the all-party House of Commons Committee on Social Services agreed on targets of 1 consultant to each junior doctor by 1988 and 1’ 8 consultants for each junior by 1996. However, as the Social Services Committee points out in its latest report, nothing approaching this has happened. The DHSS is accused of hardly trying even to find out why so little progress has been made towards a health service in which most hospital patients would be treated by consultants ("fully trained doctors", in the phrase of the committee). Pilot projects to identify reasons for the lack of progress and solutions have not been encouraged by the DHSS, the committee was told by the National Association of Health Authorities. The DHSS says that health districts "are not anxious to have the spotlight turned on them and be made a pilot project". Whatever the truth of this side-issue, the central fact is that the consultant to junior ratio has barely changed since the targets were agreed, and shows little sign of early improvement. The NAHA told the committee that such progress as could be identified was neither steady nor sustained. The Hospital Junior Staff Committee reported that progress was negligible; the President of the Royal College of Surgeons called it lamentable; and even the Minister of Health, Mr Kenneth Clarke, confessed to disappointment. The report identifies several reasons for the "chasm between intention and performance". While decisions on staffing are taken at regional and district level, there is little pressure on them from above to take any initiatives, says the committee. In the short term at least the plan would be expensive. While the committee has urged that some growth money to authorities should be earmarked for consultant expansion, the Government insists that the money must be found from the authorities’ efficiency savings. Regional strategic plans which the authorities now have to submit to the DHSS should include programmes for increasing consultant numbers, says the report. But the Committee acknowledge the cash pressures these must generate, quoting the North East Thames region’s complaint that consultant expansion will be one of the region’s "greatest challenges" if acceptable standards of patient care are still to be afforded. At its present rate of progress North East Thames should achieve 1’ 5 juniors to each consultant by 1993, a long way short of the Government target but better than most other regions. It is time for the newly installed NHS Management Board to issue to regions unambiguous guidance on how they are to reach consultant/junior targets, the Select Committee’s report urges. Some consultants have proved hard to reconcile to the scheme as a whole, the report says, though the extent of consultant resistance is sometimes exaggerated. Consultants favour more consultant posts, but are not keen on the extra work-load they will face if junior posts are reduced. "We have been made well aware of the consultants’ unwillingness to take on further or more onerous on-call responsibilities; to reduce the tiers of on-call cover; to go much further down the road of cross-cover ; and to move towards consultants sleeping
says the report. Yet many consultants are on call as it is, and many-not only those in laboratory specialties-work virtually unsupported by junior staff, the committee notes. While consultants’ leaders support change, individuals remain suspicious, and even if they support the principle "there is no incentive for a consulant to seek change at hospital level". Thus reduction of junior posts has not accompanied such minimal consultant expansion as has taken place. In many areas, especially psychiatry, reduction of junior jobs would not be expected to bring sufficient consultant expansion to meet service needs. The report rejects once again the creation of a "subconsultant" grade. "It is clear there is still no great desire among consultants for changing the basis of the medical career structure. While what a consultant is expected to do may change, there is in our view no good reason to invent new grades to conceal the difficulties." The Minister of Health and the DHSS still say they favour consultant expansion, says the report, but warns they are "unlikely to do anything if left to their own devices". But in the final analysis, the Committee insists, it is the Government which is proposing a consultant-based health service, "and it is to the Minister we are entitled to look for operational plans to bring those changes about". The Government’s restrictions on the immigration of foreign-trained doctors and on training posts in the NHS for them will make little difference in reality. The restrictions "do not appear of themselves to prevent an overseas graduate gaining entry clearance on the basis of acceptance into a training post every bit as limited as at present. Indeed, the expectation is that there will be a steady inflow of doctors for such posts". Now is the time to thrash out a proper sponsored training scheme, so that a halt can be called to the exploitation of foreign doctors in the NHS as pairs of hands in unpopular specialties. Progress in consultant expansion also requires an improved data system for the NHS as a whole. "Given the time, energy and money devoted to manpower data and computer reports over the last few years, it would be disgraceful if we did not emerge with a compatible national system", says the report.
in,"
Limited List Now that general practitioners have declared they will have no truck with a local system of appeals against the exclusion of drugs from the Government’s limited list, the Government is happy to do nothing at all. Health Ministers have no obligation to operating the limited list with no appeals system built into it, other than the regular review of the list to take account of technical advance. To this extent, the BMA seems to have made a serious strategic error in its opposition even to less-than-satisfactory appeals procedures, on the grounds that such procedures legitimise the concept of the limited list. But backbench MPs-under pressure as much from drug companies as from doctors in their constituencies-are now beginning to demand at least some sort of appeals mechanism. Questions on the subject are beginning to appear on the Commons’ order paper. One Tory, Mr Michael Latham, insists he only supported the limited list plan in the first place because he was led to believe it would include an appeals system. He regards the BMA’s stance on the matter with horror, and says he is convinced that a genuine local appeals system is vital to the interests of patients. He promises to make a nuisance of himself until Ministers see
things his way. RODNEY DEITCH
Commentary Consultant
from Westminster Numbers, Again
ANYONE seeking change for the better in the NHS would do well to study the fate of plans, laid in 1981, to increase NHS consultant numbers and reduce junior hospital posts. The Government, health authorities, all doctors’ representatives, and the all-party House of Commons Committee on Social Services agreed on targets of 1 consultant to each junior doctor by 1988 and 1’ 8 consultants for each junior by 1996. However, as the Social Services Committee points out in its latest report, nothing approaching this has happened. The DHSS is accused of hardly trying even to find out why so little progress has been made towards a health service in which most hospital patients would be treated by consultants ("fully trained doctors", in the phrase of the committee). Pilot projects to identify reasons for the lack of progress and solutions have not been encouraged by the DHSS, the committee was told by the National Association of Health Authorities. The DHSS says that health districts "are not anxious to have the spotlight turned on them and be made a pilot project". Whatever the truth of this side-issue, the central fact is that the consultant to junior ratio has barely changed since the targets were agreed, and shows little sign of early improvement. The NAHA told the committee that such progress as could be identified was neither steady nor sustained. The Hospital Junior Staff Committee reported that progress was negligible; the President of the Royal College of Surgeons called it lamentable; and even the Minister of Health, Mr Kenneth Clarke, confessed to disappointment. The report identifies several reasons for the "chasm between intention and performance". While decisions on staffing are taken at regional and district level, there is little pressure on them from above to take any initiatives, says the committee. In the short term at least the plan would be expensive. While the committee has urged that some growth money to authorities should be earmarked for consultant expansion, the Government insists that the money must be found from the authorities’ efficiency savings. Regional strategic plans which the authorities now have to submit to the DHSS should include programmes for increasing consultant numbers, says the report. But the Committee acknowledge the cash pressures these must generate, quoting the North East Thames region’s complaint that consultant expansion will be one of the region’s "greatest challenges" if acceptable standards of patient care are still to be afforded. At its present rate of progress North East Thames should achieve 1’ 5 juniors to each consultant by 1993, a long way short of the Government target but better than most other regions. It is time for the newly installed NHS Management Board to issue to regions unambiguous guidance on how they are to reach consultant/junior targets, the Select Committee’s report urges. Some consultants have proved hard to reconcile to the scheme as a whole, the report says, though the extent of consultant resistance is sometimes exaggerated. Consultants favour more consultant posts, but are not keen on the extra work-load they will face if junior posts are reduced. "We have been made well aware of the consultants’ unwillingness to take on further or more onerous on-call responsibilities; to reduce the tiers of on-call cover; to go much further down the road of cross-cover ; and to move towards consultants sleeping
says the report. Yet many consultants are on call as it is, and many-not only those in laboratory specialties-work virtually unsupported by junior staff, the committee notes. While consultants’ leaders support change, individuals remain suspicious, and even if they support the principle "there is no incentive for a consulant to seek change at hospital level". Thus reduction of junior posts has not accompanied such minimal consultant expansion as has taken place. In many areas, especially psychiatry, reduction of junior jobs would not be expected to bring sufficient consultant expansion to meet service needs. The report rejects once again the creation of a "subconsultant" grade. "It is clear there is still no great desire among consultants for changing the basis of the medical career structure. While what a consultant is expected to do may change, there is in our view no good reason to invent new grades to conceal the difficulties." The Minister of Health and the DHSS still say they favour consultant expansion, says the report, but warns they are "unlikely to do anything if left to their own devices". But in the final analysis, the Committee insists, it is the Government which is proposing a consultant-based health service, "and it is to the Minister we are entitled to look for operational plans to bring those changes about". The Government’s restrictions on the immigration of foreign-trained doctors and on training posts in the NHS for them will make little difference in reality. The restrictions "do not appear of themselves to prevent an overseas graduate gaining entry clearance on the basis of acceptance into a training post every bit as limited as at present. Indeed, the expectation is that there will be a steady inflow of doctors for such posts". Now is the time to thrash out a proper sponsored training scheme, so that a halt can be called to the exploitation of foreign doctors in the NHS as pairs of hands in unpopular specialties. Progress in consultant expansion also requires an improved data system for the NHS as a whole. "Given the time, energy and money devoted to manpower data and computer reports over the last few years, it would be disgraceful if we did not emerge with a compatible national system", says the report.
in,"
Limited List Now that general practitioners have declared they will have no truck with a local system of appeals against the exclusion of drugs from the Government’s limited list, the Government is happy to do nothing at all. Health Ministers have no obligation to operating the limited list with no appeals system built into it, other than the regular review of the list to take account of technical advance. To this extent, the BMA seems to have made a serious strategic error in its opposition even to less-than-satisfactory appeals procedures, on the grounds that such procedures legitimise the concept of the limited list. But backbench MPs-under pressure as much from drug companies as from doctors in their constituencies-are now beginning to demand at least some sort of appeals mechanism. Questions on the subject are beginning to appear on the Commons’ order paper. One Tory, Mr Michael Latham, insists he only supported the limited list plan in the first place because he was led to believe it would include an appeals system. He regards the BMA’s stance on the matter with horror, and says he is convinced that a genuine local appeals system is vital to the interests of patients. He promises to make a nuisance of himself until Ministers see
things his way. RODNEY DEITCH