RCP president: “Put bluntly, we are under-doctored, underfunded and overstretched”

RCP president Professor Jane Dacre’s speech to the BMA Special Representative Meeting 3 May 2016:

As the president of the Royal College of Physicians, I don’t really have any role in negotiating terms and conditions of service, so I’m not really supposed to be involved in the junior doctor contract dispute.

However, colleagues, I can tell you that in my entire career, I have never been so involved in an issue that I wasn’t supposed to be involved in! The reason I am so worried about it is because of the damaging effect on the next generation of doctors, and in turn on patient care – you don’t have to be the president of a royal college to realise the implications.

I was asked today to talk about morale and workload issues, and put forward some solutions for wider debate in the hall, and I am happy to do so.

The circumstances that led our junior doctors to take industrial action have been building up over a long period of time and do not only relate to terms and conditions of service. Morale was already poor, driven by a combination of:

• high pressure and intensity of work

• for those in hospital at night and weekends, being stretched beyond reason to cover far too many patients

• service issues taking precedence over education and training

• little quarter given to career planning and life issues outside of medicine by employers

• And last but not least, the spectre of having to provide a seven-day service in future when we can barely staff a five day one.

And people have been voting with their feet – the number of medical trainees has reduced during the last 4 years, reducing by 2.3% in the last year alone. We don’t have the final data for this year yet. But are certainly not expecting an increase.

Across the country there are not enough doctors to cover the current clinical workload, in particular the acute on call work. Many shifts are unfilled representing a significant risk to patient safety. Every day, trainees and consultants alike are asked to work extra shifts to cover these gaps.

Put bluntly, we are under-doctored, underfunded and overstretched.

Junior doctors already work seven days per week in acute and emergency care. Doctors are moving to other countries for more supportive working and learning environments and many are considering leaving medicine entirely. They do not feel safe, valued or supported and the imposition of the contract is the final straw.

This is a tragedy for the NHS and a colossal loss of potential.

The existing gaps in trainee rotas are also taking their toll. In the RCP’s snapshot survey of consultant physicians, we asked about trainee rota gaps, and the results are sobering:

• One in five of those surveyed report significant gaps in trainee rotas such that patient care is compromised

• Nearly half of those surveyed have had to find a workaround solution to ensure that patient safety is not compromised

• One in ten of report often having to act down to fill vacant trainee posts, and nearly a third of have acted down as a one-off.

And what of those consultants being asked to cover? Does anyone imagine that there are so many of us we can afford to step away from our own work and not create a backlog? We too have shortages, particularly in acute medicine and geriatric medicine, where NHS Trusts have created a raft of new posts to meet the exponentially rising demands for patient care, only to find that there is no-one to fill them. And our cash-strapped NHS Trusts would not be creating posts unless they really needed them.

Over the last year, our census data shows that 40% of advertised consultant posts remain unfilled, nearly always due to a lack of candidates. This is worse in acute and geriatric medicine
Let me run that past you again – ladies and gentleman, two in five of consultant physician vacancies are unfilled!

Even I was given the opportunity to act down – a few weeks ago I had a genuine email from a locum agency asking me very nicely if I could work three 12-hour shifts as a senior house officer in Acute Medicine on the Isle of Wight! How desperate is that! If the president of the Royal College of Physicians is being asked to cover SHO posts 70 miles away, if we have neither enough trainees nor consultants to run the service now, how are we going to implement a safe seven-day service?…

I can only speak for medicine, but I am sure this is not limited to medical specialties, as I can see so many of you nodding as I speak. So while much was made in the media last week of consultants taking on the role of juniors during the strike, for many of my colleagues this was nothing new – it was simply a more organised version of a depressingly familiar situation.

Let me make this quite clear – there is no lack of support for a seven-day service from physicians involved in the care of very sick patients. Our surveys show repeated support for this and over two-thirds of physicians already work across 7 days. But how are we going to do that if:

• We can’t fill the posts as there are not enough trainees in these specialties

• The trainees we do have are so fed up they are leaving

• It isn’t just doctors who provide hospital care – where is everyone else?

Consultant physicians tell us over and over again that to be able to provide the best possible care for patients at night and at weekends, we need many other services to be in place during the nights and weekends:

• other healthcare staff – nurses, radiographers, therapists

• access to diagnostic and pharmacy services

• and importantly, access to social care services so that patients ready to leave hospital can do so.

But, so far, we hear precious little about how the other support services are to be expanded or re-organised to give us the support we need. My worry, and that of other professional groups is that the squeeze on the junior doctors is only the beginning, and our other clinical colleagues are next in line. When will detailed plans for the support services be published?

As I said at our annual conference a few weeks ago, the optimism of the Five Year Forward View is beginning to dissipate in a wave of financial deficit which will start to bite deep into the day-to-day running of hospitals, resulting in more cost improvement programmes, meaning more cuts.

And we need critical additional funding for social care in the forthcoming budget. Reductions in social care funding are putting real pressure on the NHS, by preventing patients leaving hospital because social support is not available.

So now I come to the hard yards – what solutions can we propose to these intransigent problems?

The first solution is obvious – we need more doctors.
We need real increases in the specialties where the demand is increasing the most, and where we are most stretched. We need more medical school places.

Our best and brightest still want to be doctors and we should let more of them go to medical school. Over a career as a doctor, there is still an alarming drop-out rate. For every 100 doctors, we need to train 120 men and 150 women – in future we need to find more flexible working opportunities so as not to lose these talented people.

Education and training is the bedrock of our craft – it should not be playing second fiddle to an overstretched service. We should honour the protected time for training, and that holds for consultants too. Our joint training arm has already published quality criteria for CMT trainees and we are now working on similar criteria for medical registrars. This forms a wider body of work on valuing trainees and I believe that is the most important thing that any of us as doctors can do on a daily basis.

And as we do so, we must also think about the reasons we became doctors in the first place…

I was recently inspired by Don Berwick who came to speak to the RCP’s annual conference a couple of months ago. His speech centred around the need to reconnect with patients, to rediscover the therapeutic relationship. He believes we have already experienced two eras of medicine – the ascendancy of the profession with its patrician, doctor-centred approach, and the present over-regulated and over-controlled era.

We need to move into the third era – the moral era, concentrating on developing those great relationships with patients that motivate and inspire us. If we can all do that, we will be able to overcome some of the present dissatisfaction and poor morale. That needs clinical leadership.

Our junior doctors need to be valued, supported and motivated…

• Valued – for the fantastic care they give to patients, for their extraordinary academic ability, for the time they have spent learning the skills and knowledge needed to do their jobs, and for their dedication and resilience in a challenging environment.

• Supported – in their training and education, acknowledging that learning from professional activities in medicine, by their very nature, take place outside of normal working hours

• Motivated – by a culture that supports and respects them in their education, professional development, and engages them fully in designing both their future and the future of healthcare.

Then, and only then, will we begin to address the unacceptable situation that has led to me speaking to you today. Our trainees are our future. They deserve it.

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