interviews

Consulting the evidence

Evidence shows that consultant-delivered care provides significant benefits to patients and trainee doctors. Professor Terence Stephenson, president of the Royal College of Paediatrics & Child Health, chaired the steering group examining consultant-led care for the AoMRC, and discussed the findings with NHE.

To dispel the dangerous idea that it is acceptable, even in the face of huge financial pressures, for patients’ care to be led mainly by junior doctors, the Academy of Medical Royal Colleges (AoMRC) has recently published a major report called ‘The benefits of consultant delivered care’.

The report gathers evidence from case studies around the world, as well as a collection of professional opinion on the topic. Professor Terence Stephenson, who chaired the steering group that produced the report, said this evidence should be considered when future decisions are made concerning the medical workforce.

The AoMRC does not think that consultants alone can handle patient care, of course – they need the essential support of other health professionals. Prof Stephenson told us: “They can only function as part of a team.”

The report considers consultants as part of a team of workers, who will offer added value compared to a team where junior doctors are in the majority.

The training debate

“There seemed to be a debate around whether you could get away with partial training,” Prof Stephenson suggested, which would move away from the question of partially trained versus fully trained, and on to the more narrow definition of a doctor trained to fulfil particular tasks.

He said: “We wanted to engage with that and find out what the evidence is that the fully trained ‘complete doctor’ might give better care than someone trained in certain procedures or only certain illnesses or parts of a disease.”

This has implications for specialisation, as although doctors can gain recognition for further training and particular expertise, Prof Stephenson argued that the NHS needs “all-round, fully-trained consultants, not someone who’s just trained in some small part of patient care”.

The UK health service is heavily dependent on both junior doctors and those from overseas, something that Prof Stephenson would like to see changed. He said: “The UK should aim to be self-sufficient in the number of consultants it provides. The number of consultants per capita in the UK is quite low compared to some other countries.”

He argued that the service should predominantly be led by consultants, with the trainees “there to be trained”. While the AoMRC was clear that this would not mean students taught purely through lectures, it would see trainee doctors as part of a system where consultants treating patients was the norm.

7/7 services

Moving towards a seven days out of seven system of working is a current topic of discussion around the NHS, with hard research having confirmed long-held anecdotal suspicions that patients are more likely to die in hospital at weekends.

Prof Stephenson said: “Most people in the health service now think that the care you get should be the same on a Sunday as a Tuesday. We firmly believe that.”

He cautioned that this would not be necessary for all services, as elective operations or scans could be rearranged throughout the week, and the real need for seven-day care is in terms of emergencies.

The biggest obstacle to implementing such a structural change is probably due to the number of consultants available, Prof Stephenson said, something that is further limited by the European Working Time Directive.

He added: “If you want to provide a hospital service 168 hours of the week, staffed to the same degree throughout, then we’re going to need more consultants going forward.”

This is beginning to be achieved, as the number of students training to become doctors has expanded over the last ten years, as medical schools were allowed to take on more pupils. However, this benefit is still some way off due to the lengthy training process needed to produce consultants.

Protecting research

Whilst seeking to promote consultantled care, Prof Stephenson warned: “It’s very important if we move, as we wish to, towards a predominantly consultantdelivered service and a 7/7 hospital, that that’s not just achieved by foregoing teaching and training and research. These are absolutely crucial to discovering treatments for tomorrow’s patients and training tomorrow’s doctors. If we just squeeze those out, it would be very bad for the NHS and for UK patients.”

The expansion in numbers of doctors in training would allow these other vital components to be protected, whilst delivering more care at the front line, he added.

Simply rearranging doctors, leaving gaps in research and training, would be a “big mistake”, Prof Stephenson said. “The UK is at the forefront of biomedical research, we punch above our weight. That’s good for UK patients and good for UK plc and I don’t think the Government would want that threatened.

“Our training has a very high reputation around the world, people come both as undergraduates and as postgraduates to train in the UK medical system and again I don’t think we want to risk that.”

Towards self-sufficiency

The UK has historically recruited large numbers of doctors from overseas, since the beginning of the NHS. Prof Stephenson stated: “I think it’s wrong that the UK, as a developed first world country, should be relying on doctors from countries that need them. We should be self-sufficient.”

Due to the expansion of UK medical schools, the NHS currently graduates around 7,000 doctors per year. There has been a big increase in recent years, but the number of graduates is only now beginning to catch up with demand.

“When those young doctors complete their training and come out we will be much closer to being self-sufficient,” he said. “Because the NHS bears the cost of training those doctors after they graduate there’s a feeling that we can’t just have a free market. It’s always been a fixed number of places and the universities don’t have any leeway on that. If we haven’t been producing enough doctors, it’s been because the number of places have been kept down, rather than because too many people want to do it.”

Prof Stephenson suggested that this oversubscription could be as high as 2:1 people applying to places available.

Substituting doctors recruited from overseas for those trained in the UK means the NHS would have to pay the same amount, and although moving to a 7/7 service could be more costly to set-up, the benefits through productivity, fewer patients occupying hospital beds and fewer errors mean that it is “not at all clear that it’s more expensive”.

Evidence, not enforcement

The report combined evidence with opinion to provide compelling confirmation that consultant-delivered care provides significant benefits, yet the AoMRC is clear that changing current policy was outside its remit. Pay and working conditions for consultants must therefore be considered as separate issues from the benefits that a consultant-led system could offer.

Prof Stephenson said: “We were very keen that this report wasn’t dismissed simply because it was seen as us arguing for doctors to be employed on certain conditions or rates of pay. We’re saying that we think there’s evidence that fullytrained doctors in the NHS will do better.

“But it’s not for us as an Academy of Medical Royal Colleges to say what their salaries should be or what their terms and conditions are. The proper bodies to decide that are the employers and the BMA as a trade union, but it’s certainly not for us to try to dictate the conditions they should be employed on.”

Various bodies are already working to consider the shape of future training. The Centre for Workforce Intelligence is looking at how to plan the workforce of the National Health Service, one of the largest employers in the world, and is taking evidence and data from the royal colleges to inform this.

Prof Stephenson concluded: “I think it’s very timely.

“With all the turbulence going on with the NHS reforms and the emphasis on local autonomy and FT status, we should try to review the evidence that supports patients seeing a fully-trained doctor."

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