Proposals for revalidation attacked
Public health doctors believe that the General Medical Council's proposals for revalidation are flawed and unnecessary. And the opposition to the proposals was largely responsible for the overwhelming vote of no confidence in the GMC (see p 1626).
At last week's conference of doctors in public health and community health Dr Charles Saunders, chairman of the Scottish Committee for Public Health Medicine and Community Health, said that the proposals were confusing and would not prevent any of the disasters that had occurred in the past few years. “It is window dressing, like the Food Standards Agency.” He suggested tearing up the proposals and starting again.
Many public health doctors have different roles or work in very specialised areas. They wanted to know how they would be revalidated and who would do the revalidation. Dr Clive Richards (Trent) said that he would have to go through the hoops as a general practitioner and as a public health doctor.
Dr John Kemm from Wales said that dissatisfaction with the GMC's document should not be interpreted as dissatisfaction with revalidation. He wanted it introduced for all doctors.
“Is revaliation now necessary?”
The only public health doctor on the GMC, and former chairman of the BMA council, Sir Alexander Macara, said that he was out of tune with the current GMC leadership and had called for the consultation document on revalidation to be referred back. He said that he was disturbed by the impression that no reforms were made before the case of the paediatric heart surgeons in Bristol. There had been support for reaccreditation, and the previous president had introduced the performance review procedures. “The pace of reform might have been faster but the intention was there,” he said. Sir Alexander queried whether revalidation was necessary now that clinical governance and appraisal had been proposed.
One or two speakers asked why the basic medical qualification was to be affected by revalidation and not a doctor's specialist qualification. The chairman of the BMA council, Dr Ian Bogle, pointed out that there was not a specialist register for general practitioners, but he suggested that possibly one could have been created. And Dr Stephen Hajioff, chairman of the specialist registrars subcommitee, explained that it would require a change in European legislation to remove a doctor's specialist qualification.
Another GMC member, the BMA's treasurer, Dr James Appleyard, believed that the proposals were flawed. “What evidence is there that they will benefit patients or that producing profiles will distinguish between good and poorly performing doctors?”
New reorganisation offers opportunities
The latest changes in the health service—primary care groups and trusts in England and their equivalent in other parts of the United Kingdom—will offer opportunities for doctors in public health medicine to move into primary care, according to the chairman of the CPHMCH, Dr Sarah Taylor.
Dr Taylor told the conference that she supported the changes. Doctors in the discipline would be in a better position to tackle the public health agenda. There were many issues that still needed to be addressed, such as the different levels of population; coterminosity; how public health doctors would function at different population levels; and the accountability of public health doctors. There would not be a single model, but “if we do not grasp the opportunity organisations will develop without public health at its core,” she said.
But Dr Stephen Hajioff wondered what public health doctors would be left out of. He believed that commissioning was a red herring. He wanted to get back to what public health doctors were supposed to be—guardians of the public health. And Dr Stephen Watkins agreed that commissioning was not the key to primary care trusts. The important thing was the increased amalgamation of family care and community services.
Dr George Venters reported that there were eight local health commissioning groups in Lanarkshire and there had already been discussions with general practitioners about improving the population's health. “GPs are our natural allies,” he said.
The conference called for all health authorities and primary care trusts to have a properly appointed medical officer with appropriate public health training to produce independent reports on issues concerning the health care of the population covered by the authority. It also wanted public health specialists appointed to trusts to command the confidence of the local health authority's public health department.
Merit awards are derisory and should be abolished
Public health doctors want distinction awards and discretionary points abolished and replaced by additional salary scale increments. These should be paid after agreed time intervals to recognise professional experience.
Speakers called the system “an albatross” and “archaic” and not appropriate for the 21st century.
Proposing the motion from the Scottish CPHMCH, Dr George Venters said, “No one is against merit and distinction but the system is devisive and unfair.” There was, he said, wide disparity between specialties and between areas, and women and doctors from ethnic minorities were less likely to receive awards.
Dr Clive Richards (Trent) called the system corrupt. “It is unfair, unequal, biased, and debases us all.” He believed that it was a tax on all those doctors who did not receive an award.
The representative from the Central Consultants and Specialists Committee, Dr John Knox, warned the conference that if awards and discretionary points were abolished there was no guarantee that the money would be redistributed to the profession. He pointed out that £36m had been allocated to reward consultants' intensity of work, but the review body refused to make an across the board allocation. “What we need is clarity about what happens and clear criteria for making the awards,” Dr Knox said.
Agreeing with the sentiment of the motion, Dr Vasco Fernandez (Oxford) said that the time was not right. With the present bad publicity about a few doctors the public would support any proposal to abolish the system. The profession should work from within to make the system work better.
Sentiment of random alcohol testing supportedMedicopolitical digest
There was sympathy for the proposal from the BMA's medical students committee (MSC) that “doctors and other health professionals should be subject to random alcohol and drugs testing at work.” But the motion was carried as a reference so that the CPHMCH could consider how such a proposal could be carried forward.
The representative from the MSC, Miss Helena Newell, said that leaders of large corporations were subject to random testing and they did not have responsibility for people's lives. Patient safety, she said, was absolute, and such a proposal would show the public that the profession was serious about revalidation. The proposal would help detection of problems and should be linked to counselling.
But other speakers pointed to the difficulties of implementation. Dr Charles Saunders, chairman of the Scottish CPHMCH, thought that people might switch to drugs that were more difficult to detect and possibly more dangerous. And Dr Clive Richards (Trent) believed that many doctors probably used cannibinoids recreationally and these could be detected several days after use. The motion was unworkable.
The conference . . .
Called for a royal commission on public health to produce a series of independent reviews focusing on the health problems of society
Wanted the BMA's board of science to report on the minimum health requirements of housing
Urged the government to develop a long term strategy for NHS funding to bring the United Kingdom into line with the best in Europe
Believed that appraisal for revalidation should be done by colleagues in the same discipline and with relevant experience
Called for the development of a satisfying career structure parallel to that of public health medicine for those who were not medically qualified
Believed that the BMA should promote the development of multidisciplinary public health working
Urged the relevant bodies to consider incorporating the senior clinical medical officer and clinical medical officer grades into the senior hospital doctors craft
Requested the NHS Executive to allow the senior clinical medical officers admitted to the specialist register to apply for regrading to consultant and allow trusts to dispense with the need to advertise the post.
Junior doctors conference
See News p 1626
There should be no subconsultant specialist grade
Representatives of the United Kingdom's 35 000 junior hospital doctors have unanimously opposed the suggestion of a “subconsultant specialist grade.” They called for the resignation of the president of the Royal College of Obstetricians and Gynaecologists if he did not retract the proposal and decided that if such a grade became a reality the BMA should ballot its members on industrial action.
Speakers at last week's junior doctors conference in London said that the proposal for the grade, which would be open to doctors who had obtained their certificate of completion of specialist training, would close the door to future consultant expansion.
The conference resolved that such a grade would be divisive, would undermine the value of specialist training, and was merely a device to enable the royal college to avoid its responsibilities for the workforce crisis in the specialty.
“I am beside myself with rage over this matter,” Miss Fiona Kew, a registrar in obstetrics and gynaecology in Middlesbrough, told the conference. The proposal had been made to try to solve the crisis in the specialty, where there were about 400 more specialist registrars than consultant posts. But it was not supported by the whole of the college or the trainees.
The chairman of the Junior Doctors Committee's negotiating subcommittee, Mr Nizam Mamode, believed that there were many senior doctors who did not want consultant expansion because it would dilute their private practice.
“I have been a junior doctor for nine years and I do not want to be one for another 29,” Dr Trevor Pickersgill, a specialist registrar in neurology in Swansea, declared. “I have aspirations to become a consultant, but this is a cheap and dirty fix.”
There were alternatives to the proposed grade, according to the chairman of the JDC, Mr Andrew Hobart. Consultants' work patterns would change, and if there were enough consultants there would be a consultant based service and eventually a consultant delivered service. One of the consultant posts he had applied for involved resident on call and that was acceptable.
Chairman of council advises against call for resignation
The chairman of the BMA council, Dr Ian Bogle, said that by unanimously opposing the idea of a subconsultant grade representatives had expressed their views forcibly about the Royal College of Obstetricians and Gynaecologists and its president.
But he advised that calling for the president's resignation would not be helpful at a time when the Academy of Medical Royal Colleges had withdrawn from the Joint Consultants Committee over a misunderstanding about the senior hospital staff's vote of no confidence in the General Medical Council (p 1621).
Dr Bogle said that he understood that the president of the college may have changed his mind about creating a new grade. and he suggested that it would be better to try to work behind the scenes.
Doctors do not want to wait 12 years for 48 hour week
The meeting deplored the fact that it might take up to 12 years to implement the working time directive for junior hospital doctors in the United Kingdom.
The European Council of Ministers applied a nine year transition period to the extension of the 48 hour working week to doctors in training. Member states can extend this by up to a further three years. The conference called on the government to state that it will implement the directive in less than the maximum transition period.
Under the legislation each government has four years to implement its provisions on working time, rest periods, breaks, annual leave, and night work. After this, there will be a further five years during which the average working week of doctors would be reduced from 58 hours to 48 hours.
Dr Richard Brighton said that in some European countries the working week had already been reduced to 40 hours for junior doctors.
One of the JDC's deputy chairpersons, Dr Trevor Pickersgill, said that it was a health and safety issue and about patient care. “We want a health service with rested doctors and the 12 years is a ‘get out clause.’”
Mr Andrew Hobart, chairman of the JDC, said that he had written to the health secretary asking him how the government intended to implement the legislation.
Antidoctor press bashing attacked
While disassociating themselves from the words and actions of Mr Rodney Ledward, the consultant obstetrician and gynaecologist, who was struck off the medical register for serious malpractice (10 June, p 1557), junior doctors unanimously insisted that not all doctors were “tarred with the same brush.”
They declared that “the vast majority of doctors are hard working, empathetic, conscientious individuals,” and they regretted the distress caused by Mr Ledward's interview in the press in which he maintained that he had done nothing wrong.
The meeting admitted that the performance of some doctors fell below accepatable levels, but it rejected the constant barrage of overgeneralised antidoctor, particularly anticonsultant, media stories. It recognised that all hospital medical staff were working ever harder and often well beyond their contracted hours, and pledged to work with the rest of the profession and the health departments in exploring new ways of working to deliver a high quality consultant based service.
Dr Trevor Pickersgill, a specialist registrar in neurology in Swansea, said that doctors were demoralised by unattributed briefings. “Without the cooperation of all doctors the NHS would fall apart,” he said. “Reforms will not happen without our help. The vast majority of doctors are working hard and doing a very good job, and it is time that the government realised that.”
A senior house officer in accident and emergency medicine in Barnsley, Dr Kate Scheele, reported that all staff in her hospital were completely demoralised by the misinterpretations given to events at the hospital in the press. They felt undervalued, and her competence was often undermined by patients who no longer seemed to trust what she said.
The chairman of council and the chairman of the consultants' committee had both been working hard to reverse the attack on doctors, Mr Andrew Hobart, JDC chariman, told the meeting, and he believed that they were beginning to succeed. He also told the conference that the BMA's finance and general purposes committee had authorised a substantial amount of money to improve publicity even more and tell the public the good news about doctors.
The conference . . .
Believed that the education of doctors in training was best served by working patterns with a minimum of 30 hours of duty a week when a consultant trainer was present
Called on the BMA to investigate the feasibility of legal action under the Human Rights Act against trusts which flout the new deal rest requirements
Believed that medicine was becoming an increasingly elitist profession and called on the government to re-evaluate tuition fees and address student debt
Condemned the increasing pressure for doctors in training to undertake irrelevant research while waiting for a specialist registrar post and believed research should not be a compulsory part of specialist training
Resolved that doctors involved in medical management should have appropriate training provided by their employer
Believed that junior doctors taking study leave on a day when they would not otherwise be working should be given time off in lieu
Called for a working party to be established to debate and advise on the formation of a grade unifying the training of senior house officers and specialist registrars.
Number of doctors' suspensions rise
The number of doctors who have been suspended over the past three years has quadrupled, and although most are reinstated the cost to the NHS is about £20m. Of the 250 doctors suspended in England and Wales in the past 14 years—about half were in the past three years—only a third were suspended because of concerns over their practice. At present over 40 doctors are suspended.
With the backing of the BMA, Baroness Knight of Collingtree has introduced a bill into the House of Lords to make the system of suspension fairer. She condemned the current system as a “very long line of wrong, unjust, and indeed scandalous suspensions.”
The BMA wants the government to introduce a system similar to the one in Scotland whereby independent experts can be called to assess the merits of a case when a doctor is threatened with suspension.
But health ministers plan to block the bill. The department of health said that it would permit doctors who posed a danger to patients to continue to practise. “We want to see an end to these long term suspensions,” a spokesperson said. “However, they are tied in to a much wider debate about regulating doctors.”
Private consultants may increase waiting lists
Many chief executives of NHS trusts think that hospital consultants who work in the NHS and do private work have a potential conflict of interest and may be adding to waiting lists.
According to a survey of 88 NHS chief executives in England and Wales, some believe that patients treated in the NHS may suffer if consultants are performing private operations as well as doing health service work. The trust exectives want consultants' contracts overhauled so that their primary loyalty is to the NHS.
One in five of the chief executives worried that private practice could have a negative impact on the quality of care for NHS patients, while 40% said that NHS waiting lists suffered when consultants did private work as well. All of them questioned whether working more than two half days a week in private practice was reasonable.
The chairman of the BMA's Central Consultants and Specialists Committee, Dr Peter Hawker, said, “I am disappointed that trust chief executives are raising this issue when they should be well aware of the very long hours worked by NHS consultants. We are currently negotiating a new, clearer contract for consultants.”
Figure.
BMA NEWS REVIEW
Chairman of the CPHMCH, Dr Sarah Taylor, a consultant in public health medicine in Birmingham, said that the NHS changes offered opportunities for public health doctors
Figure.
BMA NEWS REVIEW
The conference was chaired by Dr Noel Olsen, a public health doctor from Devon
Figure.
STEVE BEER
Miss Fiona Kew told the meeting that she was “beside herself with rage” over the proposed grade
Figure.
STEVE BEER
The JDC's chairman, Mr Andrew Hobart, conferring with the conference chairman, Dr Ian Wilson, a specialist registrar in anaesthetics in Leeds