BY A MEDICAL CORRESPONDENT
PROPOSALS are being made by clinical leaders to bring in 7-day working for hospital consultants.
These proposals are laid out in a new paper produced by a steering group of the Academy of Medical Royal Colleges (AoMRC) titled ‘Seven-Day Consultant Present Care’.
The chairman of the group is Sir Norman Williams the president of the Royal College of Surgeons.
• For those familiar with Department of Health publications dominated by the concepts, standards and ethics proposed by McKinsey, the US management consultants, this paper is clearly influenced by the same manner of thinking.
• Although more subtly written to appeal to doctors, it is essentially demanding the McKinsey staple diet of more productivity, shorter length of stay and early discharge for inpatients, and reconfiguration of hospital care based on hospital closures.
Implicit in the document is the assumption that there will only be a few giant hospitals working 24/7, 365 days a year, doing both elective and emergency care, centralising not just frontline clinical care but backup radiology and pathology and paramedical and clerical support services.
• Anyone who is demanding a consultant presence in the hospital 24 hours a day, including at weekends, has to realise that this means tearing up the current consultant contract.
This is based on a 40-hour week, with time and third after 7.00pm weeknights and at weekends (in England) for any scheduled care, and a small extra payment for on-call responsibilities.
It is the on-call system, poorly remunerated in the ‘new’ consultant contract of 1993, which in fact currently ensures that if a sick patient comes into hospital in the evening or at night, about whom the junior doctor (registrar) is concerned, the consultant will be called in.
Consultants in acute specialties have to live within a 30-minute drive of an NHS hospital to attend such patients. This very onerous arrangement for consultants in the acute specialties like surgery and anaesthetics, has been in existence since the foundation of the NHS.
Where the understanding and teamwork between registrar and consultant is good, it works extremely well. Consultants tend to pop in on their on-call weekend and see the new patients and any of concern.
Thus at present, on-call consultants who come in to see sick patients on a Saturday or Sunday are unpaid, except for a small on-call supplement. If an operation list or clinical list is organised as a scheduled and agreed duty, by agreement between management and consultant on a weekend, then the consultant should be paid time and a third.
• The AoMRC is not a trade union. It is an umbrella body of the various royal colleges of medicine of the different specialties.
By proclaiming the advisability for compulsory weekend and evening working of consultants it knows it is straying onto territory which is not its own.
It is the British Medical Association (BMA), the main doctors union, which negotiates the contract and standard working hours, and terms and conditions for doctors.
‘Standard 1’ in the document demands that: ‘Hospital inpatients should be reviewed by an on-site consultant at least once in 24 hours, seven days a week, unless it has been determined that this would not affect the patient’s care pathway.’
It then backs off discussing the implications for the consultant contract by saying: ‘Existing out-of-hours consultant on-call rotas in the acute setting lie outside the scope of this standard.’
Well, No. In order to get compulsory consultant ward rounds seven days a week, either present on-call arrangements must be ‘in scope’, or there must be a large increase in the numbers of consultants employed.
This implication is not lost on the Director of the NHS Employers, Dean Royles. He recognises there would be resistance to the implementation of seven-day working.
His response is confrontational. He says that a pay system is required ‘that recognises weekends and evenings as normal working times. It needs to be patient care not overtime rates that drive this change forward’.
What he is saying is that consultants must come and work for free on weekends and not get the overtime payments which should be given for compulsory weekend working.
• The document then treads on very controversial ground by re-interpreting the meaning of the word ‘consultant’ in a section called Terminology (Page 10). This is an explosive subject.
Many doctors were furious when some nurse managers began calling themselves ‘nurse consultants’ when they did not have any medical training.
It is a question of demarcation. Demarcation is very important in medicine. The patient needs to know the grade and qualifications of those caring for them.
The document aspires to use the word consultant to mean – those hospital doctors with a Certificate of Completion of Training (CCT) or Certificate of Eligibility for Specialist Registration (CESR) and can be on the GMC register, AND those in the staff, Associate Specialist and Senior Specialty doctors (SAS) grade with appropriate competencies. Already the word consultant is being used to include SAS grades, whose contract is inferior to the consultant contract.
The problem comes when it says: ‘The term consultant is not meant to be synonymous with the current terms and conditions of the consultant contract. The pay and career structure for post – CCT doctors should be considered separately from issues relating to benefit, or otherwise of care being primarily delivered by consultants.’
What does this mean? Many will believe that it opens the door for a new, post-CCT sub-consultant grade, which could be set up on inferior terms and conditions, which has long been the aim of those supporting the privatisation agenda in the NHS.
l ‘Standard 2’ calls for ‘consultant-supervised interventions and investigations along with reports should be provided seven days a week if the results will change the outcome or status of the patient’s care pathway before the next “normal” working day. This should include interventions which will enable immediate discharge or a shortened length of hospital stay.’
In fact, the need to accelerate patients’ discharge from hospital is mentioned no less than 15 times in the 26-page text of this document.
Private sector healthcare is always dominated by reducing length of stay and excessive use of beds. The document is preparing the way for private hospital care.
• Standard 2 wants not only consultants but all the back up services to run evenings and weekends as well. This is to include radiology and pathology, physiotherapy, pharmacy, etc.
As explained above, these services at present are provided on evenings and weekends by on call staff. There are evening and night rotas for radiographers and path lab staff and consultants are on call for home and available to come in for serious cases.
It is true that other cover, like endoscopy, could be better provided, but all the hospital needs to do is to set up a rota and pay the gastroenterologists to provide the service. In the present climate of cuts, managements constantly refuse to do this.
So what is this all about?
First, they want all these backup clinical services working 24/7 for the hospital and for the ‘community’ (so as to provide ‘scale’ contracts – AA).
Second, they want to establish elective, i.e. cold, not urgent operating lists and outpatient clinics in the evenings and on weekends. It is in that sense that they want consultants in the building at these hours.
This key aim is buried on the third-to-last page of the document (Page 24). ‘While the standards in this report are not directly looking to make elective services more widely available, implementing the resourcing and working practices to meet the standards may indirectly enable healthcare providers to increase provision of weekend elective care in future.’
A normal person could be forgiven for believing that this document is all about improving care for patients admitted as emergencies out of hours. But this is not the main drive behind these proposals.
Anyone who has been through the experience of having a PFI building imposed on their hospital, knows that all the talk is about ‘sweating assets’. Private providers want every inch of their space and their equipment used every minute of every day to make profit.
RECONFIGURATION
The real purpose of the document leaks out where calls are made for Reconfiguration of hospital care. For example: ‘The Academy does not believe that the standards proposed in this report can be universally achieved within the existing funding and NHS tariff levels. In addition, it is likely that services reconfiguration onto fewer sites will be needed.’
• In fact, when you read through the recommendations for the consultant ward rounds every 24 hours (Page 17), they qualify this by saying that the consultant does not actually need to see every patient him/herself!
‘The method by which a consultant-led review takes place need not be constrained to formal, physical bed-side review ward rounds by a consultant. Other appropriate methods of consultant-led review could include:
‘– ward round taken by a doctor in training or a SAS doctor, followed by discussion by all, and review of selected patients by the consultants.
‘– a “broad based” multidisciplinary team. ‘Physical presence of the consultant in the clinical environment is a key component to this recommendation, so that issues arising from the daily review can be identified and appropriate actions instigated without delay.’
Of course, this requirement to be ‘in the clinical environment’ will be possible if the consultant is in the hospital doing an elective outpatients clinic or operating list.
So the document is designed to mislead. Under cover of pretending to want to improve the care of emergency patients, it in fact smuggles in the requirements of the private sector which want to:
a) promote the current reconfiguration plan to close down scores of district general hospitals and consolidate care in large hospitals with huge catchment areas, so that patients have to travel for miles to access emergency care;
b) institute 24/7 elective care in hospitals and 24/7 working of radiology and pathology at large centralised hospitals working for the ‘community’ as well, so as to ‘sweat the assets’ of the hospital, building infrastructure and staff.
No mention is made of the reality that hospitals must now become Foundation Trust businesses and make a profit and that they will seek to do this by admitting up to 49% of their patients as private patients.
As more and more private companies bid to run NHS hospitals they will want consultants on site 24/7 to look after the private patients, who no doubt will be at the top of the queue.
This document is a warning of the trouble ahead for consultants.
Already the government has laid down the gauntlet and threatened to impose changes on the GP contract, going over the head of the BMA.
The BMA must not allow this to happen to consultants as well. The unions must stand up for all its members and not be railroaded to change GPs’ and consultants’ contracts in the interests of the private sector.