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Motion made,

(1) the amount payable to a Member in any year, beginning with 1st April, shall not exceed the aggregate of--
(a) the cost of a return business class airfare for the journey on the assumption that the journey begins and ends at a London airport and that the destination is any of the

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three cities mentioned above or the location of the national parliament of a European Union member state; and
(b) twice the corresponding civil service class A standard subsistence rate for the time being in operation; and
(2) expenditure in pursuance of this Resolution within financial year 1999-2000 shall not exceed the total currently planned for expenditure on travel by Members to European Union institutions within that year.--[Mr. Allen.]

Hon. Members: Object.

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Trainee Obstetricians

Motion made, and Question proposed, That this House do now adjourn.--[Mr. Allen.]

7 pm

Dr. Evan Harris (Oxford, West and Abingdon): We are heading towards making redundant a number of ready-to-be consultants, which the national health service desperately needs and who have cost the country a fortune to train. I shall set out the figures involved, then describe the demand for consultants and consider some of the problems meeting that demand and some of the potential solutions to both the immediate crisis and long-term work force planning problems.

In a written answer from the Minister of State, Department of Health, the hon. Member for Southampton, Itchen (Mr. Denham), which I received today, I was told that there are 117 specialist registrars in obstetrics and gynaecology who hold national training numbers, NTNs, and are therefore eligible to take up consultant posts and who have obtained their certificate of completion of specialist training, CCST, but for whom there are no consultant posts available. Of those 117, 86 had been in that position for more than six months.

Similarly, it was reported in January that 112 specialist registrars holding NTNs and with CCSTs had no consultant posts to go to, of whom 23 completed their training 18 months earlier. It was envisaged then that 82 more people would be in such a position by March 1999, of whom only a few would be mopped up by newly established consultant posts and the filling of consultant vacancies from retirement and death.

The number of new CCST holders who will complete specialist training in 1999-2000 and 2000-01 has been estimated to be 188 and 122 respectively. Similarly, Department of Health figures for the next three calendar years, are 137, 185 and 100 respectively. Either way, that makes for about 500 trainees with NTNs who are eligible to be consultants and waiting for posts, on whom this country has spent a great deal of money. At the current rate of consultant vacancies and establishment of new posts, such people will mostly have to be made redundant or find other sources of income. That is clearly unsatisfactory.

According to another written answer, it costs £160,000 just to put a medical student through medical school. The cost of training a doctor up to CCST level in obstetrics and gynaecology can be estimated by adding up the element of their salary that is paid for annually through the medical and dental education levy--generally half the basic salary, except in the house officer year, when it is 100 per cent. of the basic salary. Even a quick calculation suggests that an average general and specialist training period of about 10 years costs at least another £150,000--making a grand total of about one third of a million pounds per doctor, for many of whom there will be no consultant post.

It has already been made clear to me by individuals that they will not be hanging around waiting to be sacked when the 18-month stay of execution runs out on those with certificates of completion of specialist training. They will be moving abroad or into other jobs. I have heard of one trainee who plans to become an air hostess because she cannot bear waiting around with no likely career progression.

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There is a desperate need for more consultant posts in this country. Let me make clear the current planned rate of expansion. The Department of Health has indicated that about 50 consultant appointments were made in the past year. My understanding is that about half those were vacancies through retirement and other causes and about half were newly established posts. At that rate, about 350 of the 500 trainees with CCSTs who will be eligible to become consultants over the next three years will have no posts to go to. It is a problem of degree of magnitude, not something that can be improved quickly or without the radical action that I will be urging on the Government.

This country is in desperate need of additional consultants, particularly in our obstetric units. The fourth and fifth reports of the confidential enquiry into stillbirths and deaths in infancy have indicated that about 80 per cent. of intra-partum deaths--deaths during labour--that were identified for the study, were criticised for sub-optimal care because alternative management would reasonably have been expected to make a difference to the outcome in about half the cases and might have helped in another quarter.

The confidential inquiry into maternal deaths from 1991 to 1993 raised concerns even then about a possible lack of senior obstetric consultant input into the care of critically ill women. It drew attention to inappropriate standards of care due to inappropriate delegation of responsibility for clinical management to relatively inexperienced junior doctors. The evidence from confidential inquiries shows that we are letting down the women of this country in the quality of service we are providing.

In addition, the confidential inquiry into peri-operative deaths, which impacts on gynaecological emergencies as well as operative obstetric emergencies, indicated that direct consultant involvement in emergency surgery, particularly out of hours, may have led to an improved outcome for many patients. That is now accepted wisdom and best practice in the health service.

The Minister will be aware of the cost to the health service of clinical negligence in obstetrics. It dwarfs the cost of clinical negligence and litigation in other specialties. The clinical negligence scheme for trusts has identified the importance of consultant input in the labour ward and suggested that a standard of at least 40 hours of consultant sessions on the labour ward during the working week is desirable. That was backed recently by the joint report of the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives which, for the first time, have come together to endorse clear recommendations for consultant expansion, among a range of other suggestions.

There is a need to expand the number of consultants to improve the quality of care for women and to reduce the enormous costs of litigation as a result of inappropriate care, perhaps because of inappropriate levels of experience among the doctors concerned.

According to figures I have seen, which are not disputed, only 28 new posts were established in 1998, as opposed to vacancies, of which only a similar number were filled. Yet there were 37 appointments of non-consultant career grade doctors in 1998 alone. There is no way that the Government will be able to direct the

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consultant expansion we need while there is a free-for-all in medical work force planning. Answers that the Government have given to me show that they accept that it is still a free-for-all for trusts. They say that it is for NHS trusts to decide the number and grades of staff they need. That is a free market in staff. It does not allow the Government easily, if at all, to implement their policies in terms of quality and of reducing litigation costs to trusts which are, for better or worse, concerned with making the books balance in the short term.

We have an immediate problem, and various solutions have been proposed. One solution is for those doctors to continue occupying specialist registrar posts; but that will not do. They would either block slots for new trainees, or impose an extra cost on the national health service as their slots were filled by newer trainees. Therefore, additional money should not be spent on prolonging their tenure in those posts, and any available money should be invested in ensuring quality and in solving the problem once and for all. Regardless, keeping those doctors on in those posts for much longer would continue to deprive future consultants of those training opportunities.

Another proposal is to do nothing or to fiddle about with pilot schemes, which--judging by a letter of 28 April from Mr. Hugh Taylor, the NHS director of personnel--the Department of Health currently seems to favour. The letter quite accurately describes the current stark situation, and makes no bones about the crisis engulfing medical work force planning. It is not satisfactory to wait. Staff will leave, and quality and care will not improve without direct investment in consultant posts. Regardless, it simply will not be possible to remove junior doctors, as envisaged in the letter.

The letter proposes that temporary non-consultant posts should be created for a further 12 months. Therefore, by definition, the posts--unless they are a continuation of training posts, in which case one wonders from where the funding will come--will be non-consultant career grade. It would not be possible for the health service to remove doctor posts, at either senior house officer or specialist level, by entirely eliminating slots or by not filling specialist registrar slots with visiting trainees, who are critically necessary to cover out-of-hours work rotas. Without them, the junior doctors hours initiative--which, this week, has featured so prominently in the media--will be under further pressure.

Perhaps the Government intend that the proposed 12-month extensions for doctors--who are ready to be consultants--should involve on-call duties with junior doctors filling the posts they are seeking to leave. I have heard a rumour, from the Trent region, that a doctor was promised a post in which he would receive 50 per cent. pay--the standard on-call overtime rate--but would not be paid for daytime work. Doctors would therefore be allowed to use NHS research facilities, but would not be able to make their mortgage payments.

The Government's proposals that I have seen would not be effective. Perhaps the Government are seriously considering trying to tempt trainees into some type of non-consultant career grade post--such as the 12-month temporary extension--but such a post would clearly be a blight on a trainee's curriculum vitae. They would not be a popular option. It is also not clear how the posts would be paid for. If no extra money is provided, and training slots are left as they are, the new posts will impose an extra cost. It would also not be satisfactory to seek to

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remove medical and dental education levy funding to pay for posts in other specialties. However, if extensions are required but there is no additional Government funding, that funding will have to be used.

None of those solutions is a real option. The only solution is a centrally funded expansion of consultant posts. It would cater, in waiting list initiative cases, for improved training, supervision and service; for increased cover on obstetrics wards; for decreased litigation and litigation costs; and, by investing in adequate senior medical cover, for insuring against problems in recruiting senior nurses and midwives. That is the solution, and it would be true modernisation of the health service. If the Government would only use some of their funds to fund those posts, it would solve all the problems that I have described. Moreover, it is the action that has been called for by the British Medical Association and the Royal College of Obstetricians and Gynaecologists.

The joint report which I referred to earlier called for 24-hour consultant cover on big obstetric units and 40-hour a week consultant cover with no other clinical duties on obstetric wards during the working day. That implies an increase of around 300 in the number of consultants. That is the number needed to deal with the problem in the short term.

However, there are also longer-term issues. We must try to prevent the problem from arising again and secure the consultant expansion that the health service needs to provide a consultant-based service. The solution is clearly to restore manpower controls and end the free-for-all. There should be a limit to staff grade appointments back to 10 per cent. of the consultant work force, which would give incentives for trusts to expand their numbers of consultants rather than the non-consultant career grades. Associate specialists should once again become personal appointments, not advertised as additional non-consultant career grade posts. We should create paths back to training for those in non-consultant career grades who have been lured into those posts for lack of consultant opportunities.

We should ban the creation of illegal SHOs with no staffing or training approval. It is outrageous that doctors are led into applying for those posts when they hold no training or staffing approval because there is inadequate training in the posts. We should ban the use of non-standardised posts, which lead to poor-quality care and confuse patients. If a patient sees the word "specialist", they assume that the person is a consultant. That is the European term and the term that the Government use. Instead, trusts have created trust specialists and trust grade doctors willy-nilly as a short-term, cheap, expedient way of getting through service work of a lower quality than that which consultants offer.

I accept that planning is difficult. Having too many junior doctors causes this sort of problem, while having too few can hold back the consultant expansion that could develop the specialty. The answer is clearly to have more central control of manpower resources. I speak from experience, having served on the central manpower committee, which is a joint committee of the profession, and having worked in the area for three years.

The final aspect of my solution is to give 100 per cent. of the basic salary of trainees to deans to use within the medical and dental education levy. That would be a

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powerful tool for ensuring that trusts were rewarded for consultant expansion by attracting new specialist registrar slots and would give some protection of training for juniors against the exigencies of the service. I sincerely ask the Minister to take action to solve the acute immediate problem and to take on responsibility for the long-term solution. We have a duty to women and we must not scrimp in quality care. We have a duty to trainees and we must not waste doctors.

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