or, the trouble with part-timers
Dr DERMOT J WARD
Let me suggest that a hospital consultant has four major functions:-
The medical profession is such a broad church that one of those four functions may be emphasised in different combinations and varying degrees as befits the wide spectrum of specialities and sub-specialities of Registered Medical Practioners.
I would aver that the single most important asset of any healthcare system is its doctor or doctors. Of course, the kernel purpose at the centre of any such system of medical treatment is
“when a person who is ill or believes himself to be ill, seeks the advice of a doctor whom he trusts. This is a consultation and all else in the practice of medicine derives from it. And because the community believes that this is the essential unit, it regards most highly those persons most skilled in consultation and personal treatment, it rewards them accordingly. To the persons who facilitate the consultation, the medical administrators, the community is grateful as it should be, but not more so.” Spence J. The purpose and practice of medicine.1960. Oxford University Press. pp 273-4.London.
It follows that a doctor who leads a medical team (a consultant in hospital or general practitioner outside) is the most informed person in matter of individual patient healthcare, and general public health development. This special healthcare expertise and associated duties, authority and responsibility which are and have been generally acknowledged and accepted clearly since 1858 when the General Medical Council (GMC) was formed and self-regulation introduced. As was observed at the time politicians wanted to be the controllers (external governance?) but even then the general populace so distrusted politicians the GMC was to be the public chosen order.
UK Government White Paper Working for Patients, (1989) endorsed……”The key role of consultants in the NHS in terms of their 24 hour responsibility for patient, it is they who are the leaders of of teams responsible for all aspects of the clinical of the patients under their charge”. This was not the first reminder of consultant duties and responsibilities. Earlier that year the then Chief Medical Officer, Sir Donald Acheson, had issued unequivocal clarification in the wake of food poisoning at Stanley Royd (psychiatric) Hospital in 1984 reminding them, inter alia, of consultant overall responsibility for patients in hospital (and the well established understanding that outside hospital the general practitioner is primarily responsible for the medical management of a patient).
These two documents re-affirmed accepted notions of medical responsibility and accountability. However, it is axiomatic in good general management practice that commensurate management authority is essential in achieving management goal. Be in no doubt that medical authority has been eroded and, with that, patient care standards. The detail of this is not for now. The Mid-Staffs outrage is just one example. The depths to which the loss of hospital doctor authority has sunk is perhaps best illustrated by recent Government pronouncement that ward nursing sisters should accompany consultants on their ward rounds and that the name of the patient’s consultant should be displayed on each patient’s bed. Mirabile dictu, truly back to the future of a reinvented wheel. Nothing could more vividly illustrate the loss of the sapiential authority of doctors, its being undermined by the structured authority of lay business management introduced in the NHS in 1983. (Interestingly, the fact that family doctors are self-employed – in effect running small businesses, means they are thereby more empowered in conducting terms and conditions of service with an employing authority than hospital consultant who are of somewhat less independent status as employees of a government (IRL or UK) health authority).
This is where we segue into part-timers and locums. It has long been recognised that the part timer is a slightly different animal. Let’s take a common scenario when the locum or part-timer is faced with a patient at, say, an outpatient clinic. Here, the doctor is aware of their (the doctor’s.) being relatively disadvantaged in lacking the depth of clinical grasp and and understanding (compared with the patient’s usual clinician) and perhaps, considering patient safety, decides to postpones a clinical decision. A degree of discontinuity is inevitable but hardly enough to raise eyebrows. But most people (perhaps politicians are exempt) realise that doctors need to have a break from full responsibility, that they too have to live and have a life. Another part timer might take an OP clinic once a week and is valued by the full time clinician.
In the past we have tended to accept part time colleagues as less likely to contribute the same input to functions 2,3 and 4. This too has been tacitly assumed. Frequently, these have been women in middle years with child rearing responsibilities whose contribution to the team has been well respected. Now that impact, or rather lack of it, on those 3 functions cannot readily be ignored.
Recent years have seen a creeping change becoming a seismic shift within the profession. It was blatantly highlighted by Stephen Adams, medical correspondent (Sunday Telegraph, 26, October 2014) and I quote, “Rising numbers of women doctors working part time present “a huge risk” to the NHS’, the General Medical Council is warning, with hospitals potentially having to employ many more foreign medics to plug gaps.” There has been a 50% rise in women GPs over the last decade. It has become a global issue as any simple internet search reveals. No doubt too, problems are exacerbated by the NHS as a piece in IMT, 18 Oct 2013(“A stark admonition to to emigrating doctors) amply illustrated . That anonymous consultant, based in the UK advised “In a nutshell no non-UK doctor should come anywhere near the UK or the NHS”.
Another impinging challenge is that special biological destiny of women only, child bearing and upbringing albeit with men sharing some responsibility as fathers. This most important function of mankind, can mean short and or long breaks from a medical career which inevitably places patients and women doctors at some disadvantage as continuity of patient care, a veritable Holy Grail in medicine, is inevitably impaired. That is especially upsetting for Function 1 as above.
We have just begun to face this medical and existential problem.