A summary of Dr Mark Porter’s speech to the 2010 consultants conference:
This year is different to others. We are meeting against a radically new backdrop. The political situation is unlike any that we have known for decades.
• A change in government, indeed if one would believe the coalition government a change in the very style of government.
• A programme for government that is based not on a manifesto but on negotiations between two parties, taking place after an election.
• A programme for government devised at a time when we have experienced increased levels of investment in the National Health Service, but look forward anxiously to unprecedented retrenchment and cuts in funding. So what is in that Programme for Government? As far as health goes, it is of course a programme for England. There have been advances in the other countries and the government could usefully look to them.
• The government will grant a real terms health spending increase for five years, while recognising the impact that this decision will have on other departments. This is quite remarkable, and it gives a priority to healthcare that will be keenly envied by other parts of the public sector, and I will talk more of it later.
• The government will support doctors and nurses using their professional judgment about what is right for patients.
• And, the government has announced that it will scale back the vetting and barring regime to common sense levels. As doctors subject to this injustice we should welcome this.
This programme for government is still very much one of headlines and needs to be developed along with partners. The BMA is one of those partners and we stand ready to build up initial contacts into the discussions and negotiations essential for good government to continue in a democracy.
Something on my mind, and I think that of many consultants, and also going to be the subject of a series of vigorous debates today, is revalidation. I first heard this debated in BMA Council in 1998, when the BMA offered guarded and conditional support for the concept of a periodic affirmation of a doctor’s fitness to practise. It was the subject of the liveliest debate at the Council meeting just two weeks ago, and it would be easy for me to say that little of significance has changed between the two occasions.
Schemes and deadlines have floated down the river of time like so many paper lanterns released in hope, and still not one doctor has been revalidated.
But the pace has increased this last year. Consultations, schemes and frameworks have burgeoned and tumbled on top of each other. And yet basic questions remain, about how the scheme can run and how this can be done according to basic principles of fairness and proportionality.
These questions underpinned our submission to the recent General Medical Council consultation on revalidation mechanisms. We believe that as formulated in that consultation, revalidation appears designed to describe excellence as a doctor rather than what is needed to maintain registration. As such, it could bear disproportionately on individual consultants who may be unable to provide the level and extent of the detail required to revalidate. Where is this detail if we look for it?
The information systems run by our hospitals are better at describing activity for billing than describing the quality of outcomes, although any of you checking the activity data will find the laughable coding howlers. You will understand the widespread failure of the NHS to collect and bring into appraisal, information about the quality and the safety of care that we create for patients.
For many consultants, appraisal has not been successfully implemented other than in name, and yet revalidation is to depend on strengthened appraisal.
I say this to consultants: the BMA will not tolerate the imposition of a revalidation scheme that will feel as if it was designed merely to support a multi-source feedback industry, rather than assuring a basic safe standard of practice. This conference has passed resolutions either in favour of, or implicitly accepting, revalidation as a process of quality assurance nearly every year for over a decade. We have recognised the imperative to promote and assure quality while knowing that many of the over ambitious claims for revalidation could never be made to work. During that time we have engaged with the GMC, with governments in all nations and with others in order to criticise, influence and cajole - but we have never refused to engage nor sought to oppose.
We know that doctors play a central role in patient care, and we have recognised that the old paternalistic assumption that doctors need not show that they engage in reflective learning is something belonging to the last century if not the one before.
During these last 12 years we have successfully resisted many of the more crackpot schemes. We have stated firmly and up front that revalidation should be based on regular appraisal, and agreed schemes for consultant appraisal to that end. We have moulded the process to suit both patients’ interests and doctors’ interests, believing as we do that the two are intimately linked.
I’ll nail my colours to the mast here: I do not believe that it is a credible position for the BMA to seek to reverse that at this late stage, to seek to pull out and oppose the very principle upon which revalidation is based.
By opposing we will not end this, but we will instead be cast lonely and adrift on our own sea of troubles.
We should instead be clear in our message that this project must deliver a system that is safe, effective and workable - with a substantial scaling back of lofty ambition towards more realistic principles.
Many of you will know that the secretary of state for health decided to extend the revalidation piloting work for a further year. He has written that: “In particular we will need to be able to assure doctors, employers and commissioners that the proposals for medical appraisal and the Royal College standards are proportionate ones.”
We welcome this acknowledgment that our deeply held concerns are being listened to and acted upon, and that it is possible to persuade using cogent argument, rather than precipitate action.
We must remain a partner in these developments, engaged but critical. If the government pulls out, then so be it, and I will shed no tears; but it must be ministers who do so, not doctors appearing to avoid the responsibility we owe to our patients.
We have other responsibilities to our patients. Many consultants are today wrestling with the duty to provide round-the-clock care. Reports calling for greater involvement of consultants in diagnosis, management and direct intervention come regularly now - almost all of them written by respected medical professional bodies. There is a growing consensus among the consultants who audit care at strategic and national levels that some patients need consultant involvement to be available and provided at all times - not just at the end of a telephone line, but in the hospital.
Those of you who work in emergency departments, in obstetrics units, in critical care units, delivering primary angioplasty and acute paediatrics, will know the pressures to develop new ways of consultant working, in order to provide our expertise to the sickest of patients at the time of their greatest need.
As consultants, we accept the professionalism inherent in undertaking this emergency care role. It is led by the drive for greater quality of care.
And yet it leads to tensions between groups of consultants, and tensions between the drive for quality care and the need to have a life - a work-life balance if you will.
Providing consultant cover where and when needed, is in some places leading to trouble. New consultants may be being engaged on different terms, even as sub-consultants; established consultants who thought they had left the front line role behind are being asked to undertake it again.
• I do not believe that we should establish, or that patients need, a subconsultant grade.
• I do not believe that we should evade the responsibility of providing this care.
• But I do believe that we must determine a solution ourselves.
One of the BMA’s most important tasks at this time is to attempt to resolve this predicament. We must find a way through that allows us to use the 70% increase in consultants over the last ten years, to put in place the consultant delivered service for which this investment was provided through the NHS Plan.
This last decade may come to be seen as the last time in which significant increased investment was made into the NHS. We are now entering a full blown government crisis.
We are not responsible for this crisis. The BMA is not responsible for it, doctors are not responsible for it and nor is the NHS. The public sector crisis is one of the making of both this government and the last. It is the direct result of the banking collapses and bailouts, the economic recession and the collapse of private investment and tax receipts. The shortfall is not the result of a structural deficit due to public sector spending, but rather is the result of the failure of untrammelled markets.
And yet all the talk is of a crisis in public spending. No market meltdown, but the rhetoric is of a public sector needing to be hacked back.
We cannot ignore the recent election of a new government that is determined to squeeze government spending and the public sector. The markets demand cuts and they will get cuts.
Health is sheltered to some degree. The government has announced that front line spending will be protected, and health did not feature in the six billion pound cuts announced last week. Perhaps the promise will be delivered.
And yet, what will this pledge to maintain health spending mean? We are told that we should now refer to the decade between 2000 and 2010 as the boom years, the period of unprecedented growth, and yet everyone here will know that even though this investment was real, we had to fight continuously and strenuously to protect patient services from local cost improvement programmes in every hospital, in every trust and in every community that sometimes targeted waste, but more often just targeted spending across the board. These cost improvement programmes typically ran at about three per cent a year. What is happening now, with the pledge on protected health spending?
Sir David Nicholson, the NHS chief executive in England, has become famous for his stump speech in which he demands NHS spending cuts of fifteen to twenty billion pounds between 2011 and 2014. And you, the consultants responsible for delivering the medical care to patients, tell us that cost improvement programmes in your teams, your departments, in patient services, this year range from five per cent to ten per cent and beyond.
It is clear to me that this cannot be achieved by a few efficiencies and by creative accounting, but it is an inevitable conclusion that we will have to stop doing some things that our patients value.
Already NHS commissioners are drawing up lists of health interventions that must be decommissioned. Cut. Stopped. Not done any more.
These lists are clothed in the language of evidence - and we have called again and again for medicine and surgery to be founded on clinical evidence - but they represent target reductions based on cost and volume, sometimes ignoring the potential benefit to individual patients that a consultant in partnership with a GP might agree. Instead, in the quest for wholesale reductions in budgets, lists of banned treatments are being compiled.
This is wrong.
Our role is one of patient advocacy as much as undertaking procedures, and consultants must be involved in the discussions that lead to local service reductions. Painful though it is, more painful though it will be, we cannot stand aside and let the debate be conducted between management consultants and finance directors, but must instead stand within it, bringing our experience, our evidence and our advocacy to bear.
Twenty-nine years ago, in another city and another century, a Liberal Party leader told assembly delegates to ‘go back to your constituencies and prepare for government’. Another time indeed.
I have to say to consultants today, “go back to your hospitals and prepare to protect patient services”.
So what, conference, is my view of the future?
• It is a future where consultants have to develop a narrative as to our place in patient care, and make sure that the people we work with every day understand this - colleagues and patients.
• It is a future where the British Medical Association will continue to defend and promote the interests of consultants because these are inextricably bound up with the interests of patients.
• It is a future where quality of care becomes ever more important in every aspect of all that we do, and I trust that in this the place of the consultant becomes ever more assured.
