Posts Tagged ‘Sub-consultant grade’

“Go back to your hospitals and protect services”

By Dr Mark Porter, chair of the BMA's consultants committee - 8th June 2010 4:05 pm

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. 

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“The next generation will not be up to it”

By Mike Broad - 11th November 2009 1:12 pm

It’s a truism that every generation of consultants thinks their trainees will not be as good as them. The view is often that they do fewer hours, see less cases, seemingly show less understanding and appear less committed.

This week two research papers support this prejudice.

The first, in the BMJ, suggests that it takes about 20,000 hours of practice for a surgeon to master the specialty: 10,000 hours for the cognitive skills and 10,000 hours for the manual.

This equates to 4,000 hours a year over a five-year training programme.

The authors suggest that under a 48-hour week juniors are clocking up about 2,300 hours a year making it 11,500 over a five-year period.

They quote the classic sociological analysis of surgery Forgive and Remember, which states: “Surgery is a body contact sport, there is no question about it. You can’t be a good armchair surgeon.”

I think you can probably guess their conclusions.

Can you train a physician effectively in 11,500 hours of practice? I’ll leave that one for you to decide, but the quiet acceptance of the 48-hour week by the non-surgical royal colleges speaks volumes. 

The second research paper this week highlighting the frailties of the next generation was to be found in the pages of the journal Health Policy. It examined senior doctors’ perceptions of whether their medical graduates were ready to become doctors.

The answer was a resounding “no”. Consultants and SpRs in two teaching hospitals gave less than flattering feed back on a wide range of practical and clinical skills, from the ability to perform basic respiratory function tests to prescribing and advanced communication.   

The authors in part blame the GMC guidance - Tomorrow’s Doctors - for not being more prescriptive about the skills newly qualified doctors require.

Should we smile at this time honoured tradition of underestimating the younger generation, or should we be genuinely worried?

After all, the good old bad days weren’t that good. The hours might have been longer, the commitment necessarily high, but who knows what the standards were like at times.

Of course, the other big difference was that medicine itself was simpler 20 or 30 years ago. Modern medicine is infinitely more complex and interventional, which creates another problem.  

At the same time as working hours are being reduced and training re-modelled, practice is advancing and becoming more technical and specialist. And that’s without even considering the impact of the downturn on the NHS and how that will affect training and staffing budgets in the future. Or, more consumerist and demanding patients.

This level of change is the problem and we should indeed be worried about our future standards of care. 

Few organisations are fronting up to the problem in public. In an increasingly consultant-led and delivered healthcare system, we are in real danger of having under-cooked trainees. Improved training techniques and use of technology are only going to go so far. There isn’t going to be a significant extension to work hours once more regardless of what government is in power. 

So the answers lie in either an extension to training or the creation of some half-arsed sub-consultant grade. I know which I think is better for both the profession and patients.

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Trust under fire for sub-consultant grade

By Mike Broad - 19th July 2009 12:29 pm

University Hospitals Birmingham NHS Foundation Trust has been criticised for setting up a medical workforce that differs from the rest of the NHS and introducing a sub-consultant grade.

UHB has created 40 new roles for doctors alongside its training grades, the most senior of which is called a specialist consultant.

The pay and terms and conditions of the specialist consultant role are based on the 2003 consultant contract. But the salary only mirrors that of the consultant contract for the first five salary increments (£74,504 to £83,829) after which it doesn’t progress.

Dr Mark Porter, deputy chair of the BMA’s consultants committee, said the creation of a new workforce model was “tragic” and undermines the intentions of the national training system - to produce consultants of a consistently high standard.

He said: “Doctors with the qualifications to be an NHS consultant will be taking up a job with similar responsibilities but on worse terms and conditions of service and pay, and without the same prospect of advancement.”

But Dr David Rosser, medical director of UHB, said the specialist consultant role is intended to help “a small number” of senior registrars move on to the specialist register.

He said the role will help the trust retain a number of doctors, originally from overseas, who are struggling to secure consultant positions because of bureaucracy or non-recognition of their specialties. It is also targeted at senior doctors who may or may not have their CCT and are happy to be more clinically focused than a typical consultant. 

The number of supporting programmed activities will be negotiated separately for each position. Rosser said the SPAs will range between the 2.5 and 1 depending on how clinically-oriented the role is.

Describing the workforce development as “contractual honesty”, Rosser explained that all the new roles were being introduced to retain and develop doctors. The new posts would not replace training roles and will have more training opportunities than traditional trust grade positions. Their intention is to bring people back into training, he said.

Rosser said: “I can see why the BMA are taking the stance they are - but I disagree with them. Over the years, the BMA hasn’t done enough to improve trust grade posts. The national training scheme is too inflexible to allow a large, complex trust like us to change and develop our services as we need to.”

The trust is committed to keeping these roles at under 10% of the medical workforce. “They’re the grease in the cogs of the mechanism and not a major step away from national training scheme,” said Rosser.

The BMA’s Porter said: “The big question people considering these posts need to ask themselves is - will the training be recognised?”

Hospital Dr recently reported that an alternative specialist grade is currently being road tested by David Grantham, head of programmes at NHS Employers. A briefing paper says there is a need for the grade to soak up the increasing numbers of doctors completing their training.

 

 

 

 

 

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More consultants not fewer or watered down ones

By Dr Jonathan Fielden, BMA's consultant committee chair - 8th June 2009 9:59 pm

We’ve led the teams that have cut waiting times and mortality rates. We teach and train new doctors and we develop the research base that is the lifeblood of UK healthcare. We’re leaders, innovators and we’re fighting daily to provide excellent care to our patients. Underpinned by the CCT and the national contract, the day to day work of consultants is the foundation of high quality NHS care.

The BMA has led moves to promote the concept of consultant-based care. In this model, a development from consultant-led care, consultants are involved in all major decisions affecting patient care, and undertake a significant proportion of the treatment of patients, as appropriate to their skills. This concept is now gaining wide-spread support, as is our call for focused consultant expansion.

However, in recent years the safeguards on consultant-based service have come under repeated attack, sometimes overtly, sometimes more insidiously. The initial MMC blueprint suggested the Department of Health (DH) was interested in creating ‘accredited specialists’ - a post-CCT, non-consultant role, something the BMA robustly fought.

In the wake of the catastrophic implementation of MMC, we then saw proposals for Post-CCT fellowships, which again threatened to quietly usher in a sub-consultant grade, despite a lack of workforce need, and in face of the fact that it could have amounted to a career cul-de-sac for many. Once again the BMA fought to limit these to only those areas where the training need was clear.

While such schemes have not been allowed to take root, I believe new threats to consultant-based care are likely to appear on the horizon. There are two reasons for this, one financial, one political. In the current economic climate, with the NHS being required to achieve billions of pounds worth of efficiency savings, consultants are already being targeted. Misleading editorials about our pay are starting to appear and the right-wing think tank Reform has called for 10% salary cuts.

Yet the idea that a subconsultant grade would save the NHS money does not stand up to scrutiny. Post-CCT posts, whatever form they may take, will by definition need to be taken up by doctors who have undergone lengthy training and will come in at, or close to, the base consultant pay scale. The closest current examples have been in some of the ISTCs, which have needed to offer inflated salaries to attract consultant equivalents.

More importantly, cutting back on quality will not improve efficiency - giving patients the highest possible standards of care now will save money in future. There are multiple examples of how consultants add to the efficiency, safety and value for money of service delivery; let alone of the benefits we provide leading and managing the service. We should look at better opportunities to save the taxpayer money, not least the costly marketisation agenda, PFIs and under-performing ISTCs.

The other threat to eroding the ethos of the consultant-based service is the potential move to locally negotiated contracts. We are starting to see isolated examples of advisory appointment committees being sidestepped, and more importantly hospitals advertising jobs with inadequate numbers of SPAs for new entrants. These are insidious erosions of the quality of consultant jobs. A foundation trust in Stockport recently recruited two doctors to resident on-call consultant posts in O&G - posts which did not have royal college approval, and which provided fewer than the 2.5 SPAs recommended in the contract. This happened because the trust’s foundation status meant it did not have to go through an advisory appointments committee.

Our concern is that this moves us another step away from an existing appointments process, with its national overview, and the principle of an NHS with the same standards anywhere in the country.

We shouldn’t allow any watering down of what trainees can expect from their futures and we should be looking to allow more, not fewer, of them to pursue careers as consultants. This isn’t just BMA protectionism - there is a vast amount of clinical evidence in favour of focused and planned expansion in the number of consultants. This is not idealistic; putting high quality care - driven by a consultant-based service - at the heart of a high quality service is what our patients deserve.

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Employers call for sub-consultant grade

By Francesca Robinson - 5th June 2009 5:05 pm

An angry debate over employers’ long-running intentions to introduce a new sub-consultant grade was reignited this week.

An alternative specialist grade is currently being road tested by David Grantham, head of programmes at NHS Employers. A briefing paper says there is a need for the grade to soak up the increasing numbers of doctors completing their training.

Mr Grantham suggests there should be a new hierarchy within the consultant grade. This would comprise: new consultants predominantly engaged in service delivery; established consultants performing more of a training-oriented and managerial role; with senior consultants taking responsibility for the overall running of services as clinical or medical directors.

BMA consultants’ committee chairman Dr Jonathan Fielden said the proposal is “at best woolly thinking and at worst dangerous”. The Association of Surgeons in Training (ASIT) condemns it as a “retrograde step”.

Mr Grantham, a former BMA industrial relations officer, argued that employers are becoming increasingly concerned that the number of doctors who will qualify as hospital specialists over the next ten years will substantially increase.

The new 48-hour working week and shorter training programmes mean that CCT holders of the future will not have acquired the confidence and experience of existing consultants.

This has stimulated debate among employers over the cost and nature of what being a consultant will mean particularly as the relative proportion of trainees is reduced.

Mr Grantham said some employers are already beginning to develop medical workforce models based on the hierarchy concept and in some specialties employers envisage a ‘chef de service’ model where a senior consultant oversees a hierarchy of specialist doctors to deliver a service.

“The important message that employers would want to see conveyed is that we need to look at the numbers. There is plenty of work for doctors that have been trained but there isn’t a guarantee that all of them will be needed consultant level.”

ASIT has issued a position statement which warns: “Patients request and deserve consultant-delivered care. This gold standard should not be diluted by introducing post CCT non-consultant positions in an attempt to circumvent this.”

Dr Fielden said: “This idea would not be supported by consultants because when they understand the implications of a sub consultant grade they realise it wouldn’t solve any of their problems and would potentially threaten their own working lives. This grade would create a dead end for whole cohorts of our juniors who have already been appallingly treated during the recent MTAS debacle.”

Stephen Campion, chief executive of the Hospital Consultants and Specialists Association, added: “I think it’s a very dangerous step to say that patients will be under the care of somebody who is not a consultant. One has got to look at this idea very carefully and say what on earth is objective?”

Read the BMA’s view.

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MMC reasoning reveals need for new leadership

By Lindsay Cooke, co-chair of Remedy - 25th May 2009 10:53 am

Remedy has been handed the outcome of a Freedom of Information request made by a junior doctor in January 2007, just as MMC/MTAS was about to go thermo-nuclear.

Disclosure was furiously resisted by the DoH and reading the email exchange - which is detailed on the Remedy website - one can see why.

They reveal that MMC had as little to do with improving doctor training and patient care as I have with lap-dancing.

It was a dumbing down exercise designed to impose a job culture on a profession, flush out some of the ‘awkward squad’ (senior SHOs who might not be sufficiently biddable for the government’s taste) and - and what an ‘and’ - open the door to a sub consultant grade which would ultimately allow for the culling through natural wastage of potentially the most vocal and powerful awkward squad of all - consultants. That’s my analysis, by the way, and I write this in a personal capacity. Call me paranoid if you like, but it’s not paranoia if they’re really out to get you.

So, what now? The government has succeeded in replacing an organic, evolutionary training system with something unproven and deeply unpopular.

It would appear that your institutions either colluded or were hoodwinked. The elephant is not just in the room but is monopolising the sofa and has cornered the remote control. You’ve been shafted, and grassroots doctors are catching the flak every day in tick box training, rota gaps, insecurity, general demoralisation - never mind WTD coming over the horizon at a gallop.

I’ve spent enough time with doctors in the last two years to know that you see yourselves as special and different. I think you are too. You’re the best and the brightest, and it should not be beyond you to take a long, hard, collective look at the professional, economic, political and social realities you now face, take a deep breath, scream if you need to, and then start coming up with some positive proposals - if only for the benefit of the poor bloody infantry of this process, the patients. I’m one of them which is why I have the temerity to deliver this ’Mummy lecture’ as my children call it when I go off on one. I’d trust you lot over any politician, and so would over 90% of the population.

Remedy can’t and shouldn’t lead this process - indeed, the only kind of leadership I’ll have any truck with is ‘leadership with’ not ‘leadership over’. It can, however, act as honest broker. Arguably, it’s the only organisation that can as it’s the only organisation untainted by MMC.

The challenge for the profession is whether your ivory tower dwellers or those with their heads buried in the sand will have the humility to accept the invitation - and if they do not, whether a new leadership, of ideas and values, creativity and commitment to a great tradition of public service, will emerge.

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