The state of play on UK hospital wards

I was on call when 12,500 doctors marched to demonstrate their opposition to 'Modernising Medical Careers', the government's 'reform' of medical training posts. I'd like to offer a few observations, largely relating to how out of hours medicine is practised.

Junior Doctors?
I am not a consultant, but I feel that the term 'junior doctor' requires a little qualification. I started at medical school in 1992, qualified as a doctor in 1998, and have worked as a registrar (middle grade doctor) since 2003. I am junior in that I am not yet a consultant, but I have been around for a few years and seen a lot of disease. In my first few years as a hospital doctor, I worked old fashioned shifts such as starting at 9am on Saturday morning and going home on Monday afternoon having had only a few hours' sleep. I found such shifts horrific, and although I accumulated a lot of clinical experience, the cost (both physical and psychological) was considerable.

The New Deal reduced the number of hours I had to work at one stretch. At the same time, demands whilst working increased: the number of admissions went up dramatically (I'm not sure why, but it did - daily admission rates rose from 20-30 to 60-70 on average from 2001 - 2007 in the hospitals I've worked in), and expectations of what was acceptable care rose (appropriately). Medicine has also become more complicated, with more available investigations and treatments, over the past 9 years.

Although my weekly hours have reduced (from 70-100 hours per week to ~50), there's now a lot more for a middle grade doctor to do. My shifts are now spent performing routine procedures such as taking blood samples which my predecessors would never have imagined they would have to do, whilst still also being responsible for the sickest patients, in my own (medical) speciality and on surgical wards.

As a junior medical trainee, I enjoyed the responsibility of looking after the medical problems of many patients, supervised by the 'Med Reg' (the Medical Registrar on call) who had the power to ensure that the right treatments were available to the right sick patients. I aspired to becoming the 'Med Reg'.

Now, having reached the rank of 'Med Reg' (over three years ago), although I have the experience to know what should happen to sick patients. Here are a couple of my problems as 'Med Reg':

I can't screen referrals
In the past, registrars were able to screen referrals made by accident and emergency departments and by GPs, rejecting inappropriate referrals, and identifying some patients who would have been suitable for review in an out patient clinic. Now, patients are admitted to hospital without discussing them with any doctor: a nurse takes the call. Once a patient is admitted to a medical admissions unit, they tend to stay in hospital for several days - partly because they're ill, but also because being in hospital makes one ill, in many senses of the word.

I can't send patients home for out patient review
Primary Care Trusts (who control hospital budgets) are limiting numbers of out patient clinic slots. This has two sequelae:

• GPs can't pre-empt problems and sent patients to clinic rather than wait for patients to deteriorate necessiting admission to hospital
• I can't prevent admissions by sending patients who would otherwise be admitted to hospital to out patients clinic
• If I refer a patient I know has a specific medical problem to an out patient clinic, government targets mean that the patient will wait a lot longer for review in clinic than if the patient's GP were to refer them: consequently, I have to refer them back to the GP in order that they can refer them on to the specialist clinic, leading to unnecessary delays
  

Some patients require scans and tests to investigate their problems. Access to out patient scans is limited by the numbers of patients admitted for in patient scans; also, if patients need a scan, they need it: it's better that they stay out of hospital and have their scans from home. Modern medicine needs more scans - maybe we just need for facilities to scan without admitting patients to hospital? Two thirds of my patients could go home if adequate scanning facilities were available as out patients.

Some referrals for admission are made for social reasons: "the patient can't cope at home". The answer to this problem can be found in improving access to increased social provision at home, avoiding the need for a patient to be admitted to hospital for what are initially non-medical reasons, culminating in the patient acquiring a hospital acquired infection and (at best) a prolonged stay in an expensive hospital bed.

I can't change what happens to patients in hospital
Most patients believe that hospital doctors are responsible for what happens to them in hospital, because they quite reasonably expect doctors to be in control of what happens to them in hospital. This isn't the case.

Doctors (be they the most junior, or the most senior hospital doctors) are entirely incapabable of influencing the path of patients into, through, or out of hospital. They have no influence over:

• Whether they're admitted or not (see above)
• What wards they go to - many patients end up on a ward inappropriate to their clinical or nursing needs
• How fast scans/other investigations procede: those who hold the budgets don't listen to those who request the scans
• The social/non-medical provisions for those who don't need to be in hospital
• The most mundane, but essential factors in a patient's care such as hospital transport - patients turn up to clinics late or not at all, due to lack of provision, increasing the incentive to admit everybody, just to make sure they are 'sorted out'
• Access to pharmacy facilities - even if I know someone can safely be discharged at 5pm, I'm told that pharmacy is 'closed', and that I can't send someone home on a ten day course of antibiotics - so I have to admit them to hospital!
  

Furthermore, hospital doctors have no control over factors which would make their ability to treat their patients, such as:

• Information technology provision (I can't see my patient's x-rays, but I'm told that I have to wait in a queue for 15 minutes for my computer to be upgraded to see the x-rays, or even worse, I'm told that my computer will never be good enough to look at an x-ray online, although no other ways of viewing patients' x-rays are provided)

• Secretarial provision - medical secretaries keep the NHS going, yet they are paid less and less for doing more and more, whilst NHS trusts try to 'outsource' secretarial support to call centres, failing to recognise that medical secretaries are in the NHS 'front line', taking calls from relatives and patients daily, requiring every ounce of their experience, diplomacy and tact, liaising with and allowing the clinicians they (used to) 'work for' to get on with their jobs
• The relentness imposition of 'care pathways' purporting to offer ideal standards of care for patients with particular conditions, without reference to whether they actually have those particular conditions, taking highly qualified nurses away from wards, in all detracting from the abilities from doctors and nurse to treat complex disease as they find it
  

Government targets take priority over what senior hospital doctors know is right.

Daily, as a registrar, I try to sort out small problems which influence the length of time a patient stays in hospital, and how they are followed up in clinic. I'm afraid I now end up admitting patients to hospital 'for a sort out', and am forced to accept their protracted stay in hospital as 'just the way things are'.

Surely consultants can do anything?
No, they can't, even though patients think they can. The government has completely disempowered consultants, even though they are in the best position to know what is best for patients.

Furthermore, whereas in the past, more junior hospital doctors tolerated unbearable working conditions in the knowledge that, when they became consultants, they would be able to change things for the better, consultants are no longer able to make things right for their patients.

Working conditions for consultants have also deteriorated dramatically - who would want to struggle for twelve years as a 'junior' doctor to become a consultant, only to find that they are doing the same things they were doing as junior doctors, and still entirely unable to influence what happens to patients for the better?

Bottom line

• Recognise that hospital doctors have the best interests of patients at heart, and that, given appropriate powers to control service provision, that can also find the most efficient and cost-effective way of treating patients
• 'Junior' doctors have a huge amount of experience, and should be listened to. They could help sort out medical and practical problems if they were empowered to do so, but the current system just doesn't allow them to do so.
• Maybe junior doctors aren't so junior - maybe they should be listened to more