Examination of Witnesses (Questions 147
- 159)
WEDNESDAY 25 FEBRUARY 2004
MR JAMES
JOHNSON, DR
PAUL MILLER
AND MR
SIMON ECCLES
Q147 Chairman: May I first of all welcome
you and thank you very much for coming along. We are very, very
pleased to see you here. Mr Johnson, I think you are the Chairman
of the Council, so we are grateful for the high level at which
you have consented to come along. We believe it is an important
issue and particularly in the medical sphere, so we want to handle
it as carefully as possible. We are grateful to you for the evidence
you have sent, which I personally found extremely clear, so we
are off to a good start. May I make the point that the proceedings
here are being recorded and may be broadcast or webcast, so not
only your replies, but also your asides, should be carefully considered
because they may be recorded? At the end of the session we will
send you the transcript, which you can correct, but we would like
to have it back fairly soon, because it is our intention to make
a report quite quickly, because the European Commission has set
the deadline for the end of March for consultation and we want
to get in now. Even if later on we may come back when they finally
put the proposal on the table, if we missed the period now, we
thought that would be a disadvantage. Thank you very much indeed.
We have a good number of questions for you, but perhaps you would
like to introduce your colleagues first.
Mr Johnson: May I introduce my colleagues? Dr
Paul Miller is on my right, who is a consultant psychiatrist and
Chairman of a consultants committee in the BMA. On my left is
Mr Simon Eccles, who is the Chairman of the Junior Doctors Committee.
Q148 Chairman: Would you like to make any
opening statement, but we have had your memorandum which has been
circulated to everybody? If you are happy, we will plunge in.
We are trying to deal with this by subject matter as accurately
as we can, so the first question I want to ask is not about the
full effect later on of the judgments, SiMAP, Jaeger
and so on, but the effect on junior doctors or doctors in training
of the application of the Working Time Directive in any event,
irrespective of the SiMAP and Jaeger judgments.
You have said that we would lose the equivalent of some 3,700
junior doctors and the 48-hour week would mean a loss of the equivalent
of between 4,300 and 9,900 junior doctors. Could you just elaborate
a little bit on that? The second set of figures is a pretty wide
range. Why is there such a margin? Is it cumulative or are these
separate estimates? We need to get the best estimate we can.
Mr Eccles: Understood. If I may, the figures
compare the situation at present, the last set of monitoring returns,
when junior doctors filled in what their actual hours of work
were and submitted those via their trusts to the Department of
Health, compared with both August of this year, making the assumption
that every junior doctor is compliant—appreciating that
may be quite a generous assumption—then comparing with August
2009. That figure of 3,700 junior doctor equivalents, some 270,000
hours of time, is comparing the present situation, where junior
doctors are able to be covering a hospital, either by working
or asleep in bed, covering if needed, to the situation where every
hour counts as a full hour's work and they are squeezed down to
58 hours from August this year. The discrepancy between the 4,300
and the 9,900 figures compares 4,300 which is actual hours of
work loss and 9,900 is hours of cover lost. If we continue to
require as many doctors present in the hospital available for
work as we do at the moment, we are in real trouble. If we just
go on actual hours of work lost, we are in quite a lot of trouble.
We are very happy to give you a written breakdown of how we got
there.
Chairman: That would be helpful. When
we come to write our report, we need to be quite clear the basis
on which we are arguing our case, or your case, as the case may
be.
Q149 Baroness Greengross: If we forget for
a moment the SiMAP and Jaeger judgments, which added
the last straw perhaps to the problem, there is obviously an enormous
serious crisis facing the NHS. We have just been hearing from
the TUC that they do feel, because this is unionised, or you have
official bodies, that this might be able to be agreed through
collective bargaining. Are you having consultations with the NHS
about what this might in fact mean? Are you able to settle something
a bit less of a disaster? Can you fill us in a bit on that? That
would be very helpful. What is your answer? What would you like?
Mr Johnson: We have been trying to alert the
Department of Health to the scale of the impending disaster for
at least three years, as has a number of other bodies. The Department
of Health's version is that one month ago they discovered there
was a problem. The difference is as stark as that. It is very
difficult to enter into negotiations with a body which refuses
to admit that there is a problem, although they do now admit that
there is a problem. The SiMAP and Jaeger judgments,
which are extant, are part of the problem. They mean that whenever
a doctor is compulsorily resident in hospital, those hours count
against the number of hours that it will be; 58 in August. That
is just a fact of life. The judgments will not be reversed until
and when European law is changed to reflect it differently. There
is a really serious problem there. We are now, very belatedly,
having discussions with the Department of Health. The three of
us had a meeting very recently with the Human Resources Director.
We have agreed to look at whether it would be possible to write
in guidance for the service about how to handle the crisis which
is going to occur in August and we have not as yet had any of
those meetings but we are ready and willing as soon as they are.
Whether it will or not, I do not know. I have some concerns whether
it will be possible or not, but that is the position we are in
at the moment.
Q150 Baroness Greengross: If we cannot,
other than completely opting out of the whole thing, what would
you like to see?
Mr Johnson: We cannot make a collective decision
to opt out. This is now a matter of law and the whole principle
of opt-out is that it is an individual decision and not one which
can be made for you by your firm or colleagues. Every individual
doctor has the right to opt out or not and they will have to exercise
that right in August when this comes into being. It is not something
where we can say we will do a deal, as the union in this case,
with the Department of Health; that is not in our gift.
Q151 Lord Howie of Troon: This displays
my ignorance more than anything else. You say that you have 125,000
members. How many doctors are not members of the BMA?
Mr Johnson: Of the practising profession in
the UK our membership is broadly—do not hold me to it exactly—75
per cent.
Q152 Chairman: You do not see any solution
in the near future, I understand that, but an individual opt-out
by doctors in a hospital would provide some sort of solution.
I am not saying it would be a good solution, but if you are up
against the wall, you have to think about things. That would work
as long as the opt-out has not been revised, would it not?
Mr Johnson: As long as doctors are not signing
the opt-out under pressure.
Q153 Chairman: I agree with that. That is
obviously true.
Mr Johnson: I have to say, that
the only indication we have had of the preferred way forward from
the Department of Health is that they would like doctors not to
opt out, but simply to ignore the provisions of the law, which
does not seem to be entirely satisfactory to us.
Chairman: That is a point we may have
to come to as a committee. I just wanted to clarify what potential
solution, even if bad, there might be at some stage. Can we move
on to the comparison with other countries?
Q154 Lord Harrison: Is the situation in
the UK markedly different from that of other EU Member States
so far as junior hospital doctors are concerned? Would you not
just confine your comments to junior hospital doctors? Perhaps
I could rephrase the question and ask why they are not having
an impending crisis. What do we have to learn from practice elsewhere?
Mr Eccles: The first part is to say that we
are grossly under-doctored per head of population compared with
mainland Europe. That has historically been the case and remains
the case at the moment. The second part is that we understand
from our European neighbours that many of them are now rather
more aware of the situation than they had been, particularly with
the SiMAP and Jaeger judgments. It is fair to say
that most countries believed they had worked out a way of solving
this and then the goalposts were moved, once with SiMAP,
three years ago mind you, then again with Jaeger more recently.
There are two more items, if I may. The first is that the ratio
of junior doctor service provision to consultant and senior doctor
service provision is very different in this country, the average
being about four seniors per junior and in the UK it is 1.4 juniors
per senior. At least 50 per cent of our service is delivered by
doctors in training and it has been ever thus. This provides much
greater impact from this legislation. The second is that virtually
every hospital in this country has doctors in training within
it providing service and that situation is very different from
mainland Europe where training is concentrated in far fewer centres,
so the impact of this legislation is less.
Q155 Lord Harrison: Have we anything to
learn other than that we need to increase the number of doctors
and improve the ratios? Are there other aspects which we might
learn, adopt and adapt?
Mr Eccles: Treading on ice which I can hear
cracking beneath my feet, we may need to concentrate training
on fewer sites than we presently do. That will have an enormous
impact on service provision, if we choose to go down that road.
Q156 Lord Harrison: A deleterious impact.
Mr Eccles: Indeed.
Chairman: While the point is generally
true, there are one or two Member States which nonetheless had
some difficulties; I think the Netherlands moved to change their
system a bit as a direct result of the latest changes, SiMAP
and Jaeger and so on. There is some effect but it is much
greater here. Could we go on to the pilot studies which are the
Department of Health's response to some of the problems which
are coming up? They talked to us a little bit about these.
Q157 Lord Colwyn: In your written evidence,
which I found very useful and I am grateful for that, you mentioned
these pilot schemes that the Department of Health are coming up
with and I do not know whether the "Hospital at Night"
scheme is something new or something they have been thinking about
for some while, but perhaps you could just say a few words about
that and also talk about the pilot schemes involving replacing
junior doctors by nurse practitioners and out-of-hours rotas and
medical assistants. Perhaps you could just cover that subject.
Are they going to be any help? Has it proved to be useful? Is
it going to solve the Department of Health's problem?
Mr Eccles: The magic wand. The "Hospital
at Night" scheme was originally the idea of Elizabeth Paice,
one of the post-graduate deans in London, in conjunction with
the Junior Doctors Committee of the BMA about two years ago. We
took it to the department and said we thought it was a good idea
and eventually had an agreement to fund it. I must declare an
interest here in that I am the medical adviser to that project,
because the BMA has been very strongly supportive of it. The aim
of the scheme is to change the way doctors work overnight. We
mentioned the figures. We have large quantities of cover, doctors
available for work, but not necessarily working at the moment;
not in all specialties, but certainly in some. If we are losing
that cover, the thought is that we need to change to an emergencies
only system at night, particularly between the key hours of midnight
to eight o'clock in the morning, which we really do run on skeleton
staffing levels, bearing in mind that patient safety must be maintained.
We are doing that by having senior enough people to be able to
look after the patients and enough people to be able to look after
the patients. For larger hospitals, that will result in fewer
staff than they have at present and we believe that large hospitals
can implement the Working Time Directive with relatively little
change in staffing numbers. The smaller hospitals will undeniably
need more staff than they have at present to be able to maintain
safe patient care and that is the key to everything. It also requires
an enormous change in culture. We are talking about fewer doctors
awake, working together as a team with their nursing colleagues
and, bizarre as it may seem, that has not always historically
been the case. That is moving from a culture of thinking of "my
patient" to thinking of "our patients". The four
adult pilots in the "Hospital at Night" project are
reporting shortly, it is working and it seems to be reasonably
popular, but we are a long way off being able to roll it out to
the whole service and certainly it would be very difficult to
roll it out to more than 20 to 50 hospitals by August of this
year.
Mr Johnson: If I might deal with the second
part of Lord Colwyn's question, the essence of the scheme which
Simon Eccles has just described to you is that there will be this
team in the hospital who will look after all the emergencies which
come in and arise in the hospital requiring urgent, instant attention
overnight. It will be multi-professional and multi-disciplinary.
There will not be a very junior orthopaedic surgeon looking after
the orthopaedic areas, there will be this team which will have
all the competencies necessary for the whole hospital, which might
or might not include a junior orthopaedic surgeon. If they really
need an orthopaedic surgeon eventually, there will be one at home
they can get in. It involves nurses and people who have not traditionally
done this job and the problem quite rightly alluded to is that
they are in short supply as well. There is no huge stock of nurses
we can call on to effect nurse substitution. This is why it is
quite a challenging innovation, but we have no doubt at all that
if we can get it going, and it will probably not be by August
everywhere, it will provide a much better service for patients
than we now have to get something good to come out of what is
a rather unpleasant set of circumstances.
Q158 Lord Colwyn: May I widen it very slightly?
I took something out of The Times either Saturday or Sunday
where they are talking about training for junior surgeons. They
say that the reforms in 1993, together with the Working Time Directive,
reduced training in the UK from 30,000 hours to about 8,000 hours,
which is quite frightening, and that these reforms may well take
it down to 6,000 hours. Is this right?
Mr Johnson: Absolutely correct; absolutely correct.
I was one of the ones trained under the 30,000 hours and in addition
to the 40-hour week it was being on every other day or night and
after midnight you looked after the casualty department as well.
This was in a teaching hospital. It was an awful lot of hours
and an awful lot of exposure to surgical problems. It is quite
a challenge to go down to 8,000 and ultimately to 6,000 and provide
the same level of education and the same outputs in terms of how
well trained the surgeon is. It demands a much more rigorous training
programme. We learned by osmosis and following people round. It
was the apprenticeship model. It has to be much more structured
than that now and that is another change that we have to deal
with in the future.
Q159 Lord Colwyn: It is one fifth of the
training they used to get.
Dr Miller: Those figures are ones of which we
are aware and we are hugely concerned about them. In addition
to all the things we have talked about already, simultaneously
there are further proposals from the Department of Health to shorten
training for junior doctors even further. We are enormously concerned
about the quality issues for patients and the standards of patient
care which can be expected under these dramatically shortened
hours. Yet the Department of Health do not seem to share our concerns.
What you have brought out is crucially important and if you are
able to convince the Department of Health, we should be very grateful.
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