MMC Consultation Result

Here's a summary of the results of the MMC Enquiry chaired by Sir John Tooke. All 194 pages available here.

Issue	Corrective Action
The policy objective of postgraduate medical training is unclear. There is currently no consensus on the educational principles guiding postgraduate medical training. Moreover, there are no strong mechanisms for creating such consensus. There is currently no consensus on the role of doctors at various career stages.	There must be clear shared principles for postgraduate medical training that emphasise flexibility and an aspiration to excellence.
Weak DH policy development, implementation, and governance together with poor inter- and intra-Departmental links adversely affected the planned reform of postgraduate training.	Consensus on the role of doctors needs to be reached by the end of 2008 and the service contribution of trainees better acknowledged.
Medical workforce planning is hampered by lack of clarity regarding doctors’ roles and does not align with other aspects of health policy. There is a policy vacuum regarding the potential massive increase in trainee numbers.	DH policy development, implementation and governance should be strengthened. DH should appoint a lead for medical education, and strengthen collaboration, particularly the health:education sector partnership.
Planning capacity is limited and training commissioning budgets are vulnerable in England now that they are held at SHA level.	Workforce policy objectives must be integrated with training and service objectives. Medical workforce advisory machinery should be revised and enhanced. SHA workforce planning and commissioning should be subject to external scrutiny. Policies with respect to the current bulge in trainees and international medical graduates should be urgently resolved.
The medical profession’s effective involvement in training policy-making has been weak.	The profession should develop a mechanism for providing coherent advice on matters affecting the entire profession.
The management of postgraduate training is currently hampered by unclear principles, a weak contractual base, a lack of cohesion, a fragmented structure, and in England, deficient relationships with academia and service.	The accountability structure for postgraduate training and funding flows should be reviewed. Revised management structures should conform to agreed principles but reflect local circumstances. In England Graduate Schools should be trialled where supported locally.
The regulation of the continuum of medical education involves two bodies: GMC and PMETB, creating diseconomies in terms of both finance and expertise.	PMETB should be merged within GMC to facilitate economies of scale, a common approach, linkage of accreditation with registration and the sharing of quality enhancement expertise.
The structure of postgraduate training proposed by MMC is unlikely to encourage or reward striving for excellence, offer appropriate flexibility to trainees, facilitate future workforce design, or meet the needs of particular groups (e.g. those with academic aspirations, or those pursuing a nonconsultant career grade experience). It risks creating another ‘lost tribe’ at FTSTA level.	The structure of postgraduate training should be modified to provide a broad based platform for subsequent higher specialist training, increased flexibility, the valuing of experience and the promotion of excellence.

I need to think about this!

Dawn Primarolo and the Abortion Debate

Saw Dawn Primarolo as Minister for Health at a select committee on science and technology meeting on 24th October discussing changing the time limit for abortion, broadcast on BBC Parliament.

It was truly frightening. She was completely out of her depth. She seemed to have no grasp whatsoever of the issues and was personally deeply unimpressive.

I just hope the others on the ministerial team have more of a grip on the issues.

I wonder whether the minutes of the meeting will be published, with or without all the 'ums'?

Different country (Scotland) same problems

I'm now working in Scotland. Over the last four weeks I've gained a pretty good idea of how things run in this large city hospital.

Actually, things are little different from hospitals I've worked in over the last nine years in England. Some things are better than in England - I can discharge many more patients over the weekend, as TTAs (discharge medications) are provided by ward nurses. The emphasis is more on consultant led care than in was in England - the consultants are the bosses, they are good, and everyone (nurses and junior doctors) works to deliver the service which the consultants say they want. The consultants are highly visible and involved. The patients seem to have a higher degree of confidence in the system as a whole than they did in England.

Hospital At Night, which I previously saw as a Bad Thing to be avoided, is implemented wholeheartedly and seems to work. Hard for me to say, but it seems to work better than the scratch arrangements in hospitals I've worked in before did. Dare I say it, but I think that's because, in the hospital in which I work now, I don't have the feeling that experience as a senior registrar counts for nothing. Common sense seems to prevail more frequently than it did in England. The nurses seem at ease with the way things work.

Some things are as bad as they were in the hospitals in which I've worked in England. The A&E (sorry, ED) service in my city is well funded and well provisioned in terms of infrastructure (as in previous English hospitals). The MAU/ARU/EMU is a dump, badly arranged making the logistics of managing patients more difficult than it should be. Patients are queued up in wheelchairs in corridors waiting to be seen and waiting to be sent to speciality wards. This is in contrast with surgical admissions areas which are cosmetically and functionally superior - no change there then.

I grew up in Scotland but trained and worked in England before my current post. I'm getting used to the fact that, here, 'national' means 'Scottish' and 'UK' means little. The NHS means The NHS In Scotland. Thus far, and allowing for my anxieties about the pan-UK funding of health care in Scotland, I can see why it's a good thing to focus on Scotland - Scotland is a region of the UK like any other, and it's of critical mass for appropriate decisions to be made about health care resource allocations within Scotland. I have a feeling that Scotland gets more £££ than other parts of the UK (flame alert!) but they seem to allocate resources very appropriately.

I've always been impressed by how relatively recently qualified doctors cope with the challenge of being a supposedly autonomous practitioner, whilst being disempowered by their training and assessment systems which lead them to believe that their talents and training should not qualify them to push for what is right for a given patient. In this respect things are no different in my current (Scottish) hospital to the way they are in England.

Discuss.

MMC breaking up the National Health Service

A friend who, despite being a member of the Royal College of Surgeons with several years' experience working as a registrar in her speciality, didn't get an ST3 post in the fatal tombola that is MMC.

Nothing strange there, you might say. But her hubby, also a doctor, who is a Specialist Registrar, managed to get himself a two year research fellowship - in Scotland. The couple currently live in England.

She had originally been interviewed for a Scottish MMC job but been unsuccessful. Well after the MTAS debacle was over she thought she'd have another for jobs in Scotland. When she telephoned MMC Scotland she was told that she's not eligible to register to apply for a job in Scotland as she isn't working there at the moment.
The Scottish Executive has apparently guaranteed that doctors currently employed in Scotland should get some form of employment in the new MMC system. This is apparently being achieved by excluding those who weren't previously employed in Scotland from applying for MMC jobs in Scotland.

Thumbs up to Scotland for protecting their own - but surely this 'closed shop' where those not currently working in Scotland can't apply for Scottish jobs can't continue ad infinitum - MTAS is over (although the silliness of MMC continues). To deny a UK doctor a job in Scotland seems entirely contrary to natural justice, particularly given that she's married to someone who will be working there for the next two years. And isn't it a National Health Service?

Apparently similar things are going on in Northern Ireland. Yet another negative consequence of the Government's meddling: the fragmentation of the NHS. Divide and conquer?

Hewitt Resigns

Good. 

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

Arterial blood gas syringes - false economy

When someone is (potentially) really ill, doctors take a sample of blood from an artery (usually the radial artery, in the wrist), giving information about the acidity of the blood (normally very tightly controlled, acidity being a sign of serious illness), and the amount of oxygen and carbon dioxide in the blood stream.

This is particularly useful when assessing whether a patient's lungs are working properly, getting the oxygen in, and the carbon dioxide (exhaust gas) out, of the blood.

Taking blood from an artery is more difficult, and is potentially more dangerous for the patient, than 'normal' blood samples, which are taken from a vein.

Veins are larger, making them easier to stick a needle into, than arteries - arteries are smaller, and more muscular than veins, making them harder to hit.

The easiest artery to take blood from (the radial artery) is right over a bone, so even a competent doctor may prang a bone attempting to sample blood from an artery. Bones are richly supplied with nerves, so pranging a bone whilst attempting to get blood from an artery is very painful. Also, sticking any needle through the skin at the wrist is more painful than, for example, doing the same at the elbow (the most common site at which blood from a vein is sampled).

Almost universally, blood taken from veins is drawn using a system in which a vacuum draws blood from the vein into a tube. This means that you only need two hands to take a venous blood sample - one to steady the vein/skin, and another to hold the needle/collecting tube.

In most hospitals, arterial blood samples are taken using a syringe which, whilst not vacuum-driven, fills on its own once the needle is in the (high pressure) artery. You only need two hands. Hold/position wrist with one hand, stick needle in artery with other hand, syringe fills with arterial blood.

In the hospital in which I'm working at the moment, we have to use syringes which don't fill on their own. The doctor (and it always is the doctor, nurses don't do this) has to use one hand to stretch the skin/hold the wrist, one hand to stick the needle in the artery, and then shuffle the fingers of the hand holding the syringe up the syringe barrel to the plunger, and pull the syringe plunger back to fill the syringe, hoping the needle doesn't fall out as this shuffle is performed.

Trust me (but do you?), I've done hundreds of these, with a self-filling syringe arterial sampling hurts more than sampling venous blood, but is more or less guaranteed to get a useful sample with only a little prodding around.

Since returning to this hospital and using non-self filling syringes, things have become a lot more difficult. I can do it, sure - I've spent many years sticking needles in things - but I remember my time at the same hospital when fresh out of medical school, when it would often take me a lot longer, with a lot more painful stabbing around, to get a sample.

Furthermore, when using self-filling syringes, I know I'm in an artery - because the syringe fills on its own. Using a non-self filling syringe, I have to draw the plunger back myself - I'll get blood into the syringe whether the needle is in an artery or a vein (or a mixture or the two). The machine we use to analyse the sample can't tell whether the blood is from an artery or a vein (or a mixture of the two), but to properly interpret the results (acidity, oxygen, carbon dioxide) you have to be 100% certain which (vein/artery) it can from.

Results from this test commonly dictate whether a patient is put on a ventilator, referred to ICU... it's so important. If a patient needs an arterial blood sample, they're potentially very sick (although I think Accident & Emergency departments do too many of these samples on patients who aren't actually very sick).

So why don't we use self-filling syringes where I work now? Guess what - they're more expensive. A few pence for a non-self filling syringe. 50p for a self-filling syringe. The opportunity cost in using the cheap option? Missed arteries, repeat samples, venous or mixed arterial/venous samples. Pain, erroneous results. If we weren't able to spot dodgy samples (and some doctors aren't), bad decisions could be made from arterial sampling.

Another example of how cost-cutting can damage your health, and be painful.

I'll be doing my best to put a case for changing things at the hospital I work in now.