Annex A
Thank your for your diplomatic reply.
Please forgive my disappointment.
While not doubting your intention to successfully
condense necessary training into a 48-hour week perhaps you will
consider the following points:
1. Protected teaching time will not diminish
and therefore the proportion of time left to see patients will
diminish further than the arithmetical reduction in working hours.
2. A shift system will require more time
to hand over the care of more patients, further reducing the time
left available to see patients.
3. Alternating shift patterns are a source
of sleep disturbance with potential neurological consequences,
let alone effects on performance that may be greater than currently
supposed.
4. Increasing cross-cover and shorter time
available per patient will make it increasingly difficult to achieve
adequate clerking let alone consult old notes and correspondence.
Given the potential for inadequate clerking and increasingly illegible
notes it may become increasingly common for successive shifts
to have to re-clerk problem patients for themselves, further reducing
efficiency and safety.
5. With insufficient junior staff at present
to cover the needs of the Working Time Directive more consultant
time will be taken up carrying out junior doctors' work, leaving
less consultant (and registrar) time to supervise and train junior
staff. Learning instead from pathology that was, in retrospect,
avoidable is hardly acceptable (and even this opportunity might
be lost to the junior staff concerned if the Working Time Directive
precluded their being present at the time of retrospective discussion).
6. However empathetic, doctors may find
it difficult to deal with increasing numbers of unfamiliar patients.
Equally, patients seeing increasing numbers of unfamiliar doctors
may experience some confusion and fatigue. It is common enough
now to meet patients who have either gained the impression that
a succession of different doctors do not seem to know what is
going on, let alone who is in charge. Loss of continuity of care
may also result in an increase in the number of (so far rare)
patients found complaining that no-one has seen them for several
days (despite the best efforts of nursing staff to make contact
with appropriate medical or surgical staff).
7. It is clearly imperative that someone
should be in charge of individual patients, however complicated
their case may be. This must become increasingly difficult as
working times diminish for junior staff and in time for consultants.
I suspect patients would prefer responsiblity for their case to
remain with an individual, named consultant, however much corporate
responsibility we all take for shared care.
8. Most medical discharge summaries are
dictated by SHOs or registrars. As junior doctors' hours fall,
number of SHOs increase, and length of stay in each post shortens,
diluting contact of individual SHOs with patients and other members
of staff, there has been an impression at all hospitals visited
that it is becoming more difficult to find informative discharge
summaries when reviewing notes. In some cases only a handwritten
note appears to be provided to GPs, with a copy, not always legible,
filed somewhere in the notes but with no copy on computer, should
the notes be unavailable.
Dictation of discharge summaries not only allows
the opportunity to check details and ensure that everything is
present and correct and has been carried out as intended, but
also to reflect about and learn from the case and imprint it further
upon the memory, providing a valuable learning opportunity.
9. Just as small decrements in bed or theatre
capacity led in time to very large waiting lists it seems possible
that small differences in the amount of supervised clinical experience
may lead over time to very large discrepancies in knowledge that
may themselves take years to recognise and remedy, with potentially
serious consequences for many patients.
10. A shorter working week must increase
the tendency to super-specialization. This must not only waste
potential talent but also put patients at serious risk if their
illness falls outside the experience of staff on-call.
11. If 48 hours is to become mandatory for
junior staff on grounds of health and safety it should also presumably
be applied to consultants on the same basis. This must have serious
implications, given that consultants work on average for more
than 48 hours per week for the NHS.
12. If the unimaginable should happen and
the government decreed that medical staff, government ministers
and UK judges would henceforward be required to utilise the NHS
only and take their place at the back of the NHS queue, one might
see the Health and Safety Executive being persuaded very rapidly
to take a different viewpoint and consider giving patients greater
priority for their own health and safety. In the first instance
management might be required to spend more money on medical staffing,
with a view to employing more staff on-call at any one time in
order for many hands to make light work. Given current numbers
of staff it would clearly be necessary for individuals to work
a little longer on average than at present. If bed numbers and
theatre capacity were restored to meet demand it would be possible
once again to run regular daily emergency surgical lists
at a convenient time each evening in all hospitals, well before
anyone's bedtime, and admit patients for elective inpatient surgery
without fear of cancellation.
13. I think it is fair to say that the DoH
seems to have the impression that senior consultants are in a
position to protect patients from more recently appointed consultants
if the latter turn out to be under-qualified. This seems over-optimistic.
While senior consultants may gladly give as much general advice
as possible or see patients on request it is unrealistic to expect
specific management advice to be given and responsibility assumed
without a formal invitation to see the patient in question. It
would not be possible for a senior consultant to remain available
at all times for this purpose. If my interpretation is correct,
the DoH would be even more at fault if junior consultants in question
failed to recognise their limitations and did not seek advice.
14. You may recall Mr David Nunn's letter
to the Daily Telegraph. You may feel that this was an exaggeration
and that it should still be possible for UK trained graduates
to be capable of safe general and orthopaedic surgery. Nevertheless,
I wonder what you would find if you were to ask all consultant
surgeons who had been in post for between five and 10 years with
regard to the number of operations of each type that they had
personally performed before feeling fully confident that they
consistently matched nationally recognised minimum morbidity and
mortality rates, if such exist or, failing this, the number of
operations of each particular type they would feel it necessary
to have performed satisfactorily before feeling safely qualified
to operate upon a colleague or a member of a colleagues' family.
I do not know what the current requirements are but suspect that
the latter suggestion might prove more rigorous. I don't suppose
that it would be possible for surgeons to practice sufficiently
to be able to perform just as well in their sleep. On the other
hand, it becomes increasingly difficult to believe that surgeons
with much needed skills would deliberately accept restriction
to a 48 hour working week if greater NHS efficiency allowed them
to work longer hours, given sufficient sleep.
15. A newspaper today observed that the
export of British manufacturing to France had made it impossible
for the QE2 to be built in this country. Adherence to the Working
Time Directive may yet have a similar effect on medical provision
in this country, particularly if adherence proves more strict
here than abroad.
16. If this country does achieve the increase
in medical staffing required, both to meet the Working Time Directive
and subsequently to reduce waiting times, there would appear to
be a serious risk that Government finance will be insufficient
to maintain medical salaries and pensions at a sufficient level
to recruit the best candidates.
17. The full shift system is clearly unpopular
with current junior staff and may deter recruitment. It is not
inconceivable, if the Working Time Directive is implemented that
the Government will be forced to require consultants, despite
the new contract, also to be included in the full shift system
perhaps for much of their careers, with further repercussions
for recruitment. In general the effects of sleep disturbance resulting
from alternating shift patterns increase with age.
18. It is perhaps in the nature of the Directive,
and in keeping with EU matters in general, that there has been
no formal explanation, let alone discussion, of the evidence upon
which the Working Time Directive is based. To the best of my recollection
it was introduced originally simply to reduce the rate of unemployment
amongst doctors in Italy and Germany after each country had trained
more staff than were required.
19. If there are genuine health and safety
concerns for doctors it would seem more appropriate ethically
for the NHS to spend its time looking for innovative ways to allow
longer, but less intense working hours to provide the capacity
for necessary work to be done promptly and standards of care,
clinical experience and training to be improved rather than diminished.
No-one is forced to become a doctor or a surgeon.
No doubt there are many additional points to
come in this looming nightmare.
I should be delighted if you are able to waken,
and reassure me, but have to say that the comments of many colleagues,
junior and senior would seem to suggest that it is the DoH and
its advisers and the European Commission that have failed to appreciate
the consequences of the Working Time Directive for the NHS, and
for European medicine in general.
It seems utterly remarkable, given the insistence
upon audit and evidence-based medicine that a reduction in clinical
experience of more than 50 per cent during supervised clinical
training (even before any reduction in the number of years of
training) and over a clinical lifetime can be envisaged without,
as far as I can see, at least an attempt to measure the effect,
let alone preserve some system to reverse the process if it proves
deleterious. Reliance upon information technology to replace experience
seems likely to be premature.
In my experience, other attributes being more
or less equal, the most venerated teachers and the most effective
consultant surgeons and physicians have invariably been those
with the most experience, appearing to learn at least as much
from dealing with patients as from reading the scientific literature,
much of which is itself a testament of observational experience.
18 March 2004
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