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Attitudes of consultant physicians to the Calman proposals: a questionnaire survey

^a Ealing Hospital, Southall, Middlesex UB1 3HW, ^b St Mary's Hospital, London W2 1NY

Correspondence to: Dr Mather.

Abstract

Objective: To determine the views of a large and representative group of consultant physicians on the Calman proposals, in which acute general medical services will change from being primarily consultant led to consultant provided.
Design: Postal questionnaires.
Subjects: All 236 consultant physicians in acute hospitals in North West and South West Thames regions.
Results: Replies were received from 179 (76%). One hundred and thirty seven (77%) indicated that they would not resume emergency residential duties, and 126 (71%) indicated that they would probably withdraw from general medical duties under these circumstances. One hundred and twenty six (70%) and 137 (77%) had not inserted a central venous line or temporary pacemaker, respectively, within the previous five years. Of 157 answering a question on the impact of the Calman proposals on the quality of patient services, 125 considered that it would be detrimental, and only 18 (11%) thought that it would be beneficial.
Conclusion: Most consultant physicians are not prepared to resume emergency duties and could not do so without retraining in practical procedures. There is widespread antagonism to the Calman proposals, and most physicians consider that their impact on the quality of patient services will be detrimental.

Introduction

The Calman report proposes radical changes to the training of junior medical staff that will fundamentally alter the delivery of acute hospital services from being primarily consultant led to consultant provided.^{1 2} A reduction in middle grade junior staff will be accompanied by an increase in the number of consultants, who will participate directly in emergency care. These changes have been made explicit in a recent paper from the Committee of Postgraduate Medical Deans (COPMED) and the United Kingdom Conference of Postgraduate Deans, which states that "involvement of the consultants in the provision of emergency care will need to be extended and formalised into their job plans."³

The impact on consultants in acute specialities will be profound,⁴ especially for physicians in acute general medicine, because of the need for 24 hour cover. Yet there has been surprisingly little reaction from consultant physicians themselves. The Royal College of Physicians and the BMA have both given qualified support to the proposals but have made no attempt to ascertain the views of those colleagues who are most directly affected. We therefore sent a questionnaire on behalf of the North West Thames Diabetes and Endocrinology Specialist Group to a large and representative group of consultant physicians to elicit their views on these issues.

Subjects and methods

A confidential questionnaire was sent in March 1995 to all 236 consultant physicians in North West Thames and South West Thames regions whose junior staff participated in emergency intake duties. They worked at five teaching hospitals and 25 district general hospitals. We received 179 (76%) replies, and the response rates from teaching hospital and district general hospital consultants were 82% (54/66) and 74% (125/170) respectively. The respondents comprised 154 men and 25 women, and their median age was 45-50 years. The largest speciality groups were diabetes/endocrinology (35), geriatrics (34), gastroenterology (29), respiratory medicine (27), and cardiology (22).

Results

The attitude of consultants to regular residential emergency duties--One hundred and thirty seven (77%) consultants indicated that they were not prepared to return to regular residential emergency duties, and only two (1%) replied "yes" to this question (table I). Ninety one (51%) indicated that they would contemplate withdrawal from acute general medicine duties if asked to resume residential cover, and a further 65 (36%) indicated that they would "possibly" or "probably" do so. Thirty (17%) indicated that they would retire from the NHS altogether under these circumstances, and a further 96 (54%) indicated that they would "probably" or "possibly" do so.

TABLE I--Questions and responses on Calman proposals from 179 consultant physicians. Figures are
numbers (percentage)
-----------------------------------------------------------------------------------------------------------
Question                                                              No      Possibly    Probably    Yes
-----------------------------------------------------------------------------------------------------------
If you were asked to return to regular residential emergency duties,
  would you be prepared to do so?                                   137 (77)   29 (16)    9 (5)      2 (1)

If you were asked to return to regular residential emergency duties,
  would you contemplate withdrawal from acute general medical        19 (11)   30 (17)   35 (20)    91 (51)
  duties?

If you were required to return to regular residential emergency
  duties would you retire from the NHS altogether?                   51 (29)   66 (37)   30 (17)    30 (17)

If you have not inserted a temporary pacemaker within the past five
  years, are you prepared to undergo training to "relearn" this and
  other practical procedures?                                        64 (47)   42 (31)    6 (4)     24 (18)

Do you think that full implementation of the Calman proposals,
  leading to a consultant provided service, will ever occur?         60 (34)   80 (45)   31 (17)     7 (4)

Recent experience of various practical procedures--Only 21 (12%) and 19 (11%) consultants--predominantly cardiologists--had inserted a central venous line or temporary pacemaker within the previous year (table II). One hundred and twenty six (70%) and 137 (77%), respectively, had not done so in the previous five years. This latter group was asked whether they would undergo training to "relearn" these procedures (table I): 64 (47%) replied "no" and only 24 (18%) gave an unequivocal "yes."

TABLE II--Number of years which have elapsed since consultants performed various practical procedures
------------------------------------------------------------------------------------------------------
Question                                   <1    1-5    5-10  10-15   15-20   20-25     25-30    Never
------------------------------------------------------------------------------------------------------
How many years have elapsed since you last
 inserted a central venous line?           21     31     26     31      32      14        1       22

How many years have elapsed since you last
 inserted a temporary pacemaker?           19     23     32     35      22      13        2       33

How many years have elapsed since you were
 regularly in charge of a cardiac arrest
 team?                                      7     20     36     32      41      27        6        8

Views on the impact on quality of patient services--Consultants were asked, what impact will full implementation of the Calman proposals have on the quality of patient services at your hospital? and to indicate their answer on a scale of 0 (detrimental) to 10 (beneficial) with a score of 5 indicating a neutral effect (figure). Of the 157 who answered this question, 125 (80%) gave a score of below 5, signifying a detrimental impact, and 83 (53%) gave a score of 2 or less, implying that this would be profound. Only 18 (11%) gave a score of 6 or more, indicating benefit. The mean score was 2.7; and those of district general and teaching hospital consultants were virtually identical (2.8 and 2.6). The means of colleagues aged either more or less than 45 years were similar (2.3 and 2.6). The means for each speciality were broadly similar--namely, 1.6 (gastroenterology), 2.5 (cardiology), 2.7 (respiratory medicine), 2.8 (diabetes/endocrinology), and 3.3 (geriatrics).

View larger version (26K): [in this window] [in a new window]   Views of consultant physicians on impact of Calman proposals on quality of patient services at their hospitals. Consultants were asked to indicate their answer on a scale of 0 (detrimental) to 10 (beneficial) with a score of 5 indicating no effect

Views on the likelihood of full implementation of the Calman proposals--Sixty (34%) colleagues considered that full implementation would never occur, and only seven (4%) responded with an unequivocal "yes" (table I).

Other comments on the Calman proposals--Respondents were asked, have you any other comments to make on the Calman proposals in general, and their potential impact on your clinical services in particular? One hundred and twenty respondents gave answers ranging in length from a single word to several paragraphs. We have summarised their responses by listing points made by 12 or more colleagues in table III.

TABLE III--Synopsis of other points made by respondents about Calman proposals and their impact on
clinical services
----------------------------------------------------------------------------------------------------------------
                                                                                                      No of
Synopsis points                                                                                    respondents
----------------------------------------------------------------------------------------------------------------
Enormous (unrealistic?) consultant expansion required to make up for the shortfall in junior staff      22

Little or no prospect of obtaining sufficient funding for this consultant expansion                     19

Emergency duties will markedly decrease input into outpatient clinics and other specialist work         18

Emergency duties will markedly decrease input into management, teaching, and other duties               16

Consultants may not possess the stamina to undertake regular residential emergency duties               12

Acute medicine will become an unattractive career choice, leading to recruitment problems               12

Discussion

We undertook this study to ascertain the views of a large and representative sample of physicians on the Calman proposals. It has given many colleagues their first opportunity to express an opinion on these vital issues, and the impressive 76% response to a single mailshot of an intrusive questionnaire testifies to their interest and concern.

Several firm conclusions may be drawn. Firstly, nearly all consultant physicians currently in post are not prepared to return to residential emergency duties. Some emphasised this with comments such as "absolutely not" and "under no circumstances whatsoever." It remains to be seen whether consultants appointed in the future will be any more willing to undertake residential duties.

Secondly, most colleagues have no recent experience of important practical procedures and could not resume first hand emergency duties without specific retraining. Several also doubted whether they could withstand the long hours and sleep deprivation. Junior staff were thought to provide more stamina and a higher standard of practical skill than would most middle aged consultants.

Thirdly, many consultants felt that full implementation of the Calman proposals was unlikely to occur. This may explain the passive attitude of some colleagues to these issues. The need for an enormous and possibly unrealistic expansion in consultant numbers, the lack of additional funding, and the inability to maintain a supply of suitable trainees were given as reasons for their scepticism.

Fourthly, and most importantly, nearly all consultants thought that the proposals would have a detrimental effect on the quality of patient care at their hospital. This clear consensus view emerged equally strongly from teaching and district general hospital consultants and from colleagues in all specialities. This is in sharp contrast to the expressed aims of the Calman proposals, which are intended to improve patient care, but is nevertheless the informed opinion of a large and representative group of senior clinicians who are actively concerned in day to day patient care and are well placed to assess their potential impact.

These results emphasise the widespread concern and deep antagonism of most consultant physicians towards the Calman proposals. We would be very interested to know whether these views are shared by other groups of colleagues, particularly by those in the training grades.

We thank all colleagues who completed the questionnaire.

Source of funding: None.

Conflict of interest: None.

1. Calman K. Hospital doctors: training for the future. The report of the working group on specialist medical training. London: Health Publications Unit, 1993.
2. Calman K. Hospital Doctors: training for the future. Implementation of the report. London: Department of Health, 1994. (Circular PL/CMO (94)5.)
3. Committee of Postgraduate Medical Deans (COPMED) and the UK Conference of Postgraduate Deans. SHO training; tackling the issues, raising the standards. January, 1995.
4. Charlton BG Service implications of the Calman report. BMJ 1993;307:339-40.

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