Responding to changeBMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7076.2 (Published 25 January 1997) Cite this as: BMJ 1997;314:S2-7076
Job plans and team working are two ways in which consultants can manage the pressures that the changes of recent years have brought. The treasurer of the Royal College of Physicians, John Bennett, outlines the college's latest report
What do you think about when someone suggests “structuring your career” or “planning for optimal performance in later years”? Don't tell me, your eyes glaze over as you contemplate the likelihood of getting through the next medical take, let alone the next 40 years.
That is precisely why the Royal College of Physicians recently took a long hard look at the way in which a medical career is structured, or more often not structured. Most doctors are far too busy to look at the issue in depth themselves so we decided we had to take this forward ourselves.
It has become increasingly obvious that the past five years at the coal face in the NHS have taken a heavier than usual toll on physicians, with committed doctors seemingly queuing up for early retirement at a time when stability above all things was needed. Many factors - loss of morale, increasing demands of patients, growth of managerial and administrative tasks, and the effects of Calman have made us realise what a pounding consultants have taken and ask whether we could do anything to make it better not worse.
When in doubt, set up a working party - but this time make it produce a no waffle, nitty gritty document that concentrates on the aspects of the work we do have control over - job plans, the set up of the medical team, and the issue of medical professionalism. Changes in all these areas that suit both physicians and their hospitals can help in long term planning of a career. More control will lead to more job satisfaction, which in turn leads to better performance, which has obvious benefits all round.
Clues for successful career
The most important recommendation of the working party is that as a consultant you should not expect to be doing the same work as you near retirement that you did when you first started the job. The clues for a successful career are in the shifting sands around the sphinx, remaining as inscrutable as the sphinx itself, immovable as the medical world changes around it, is not an option. Different tasks should take preference at different stages in your career, reflecting the experience that you have gained and your limitations. Job plans should also be tailored or influenced by the type and complexity of work as well as an individual's age.
In times past there was little or no direction or control of consultants' work. They were usually appointed on the basis of a limited job description, often little different from that of the retired predecessor. A consultant's conscience and a certain amount of peer pressure were the only factors which determined what he or she actually did. It was not unknown for people to be seen, within a few months of appointment, doing quite different things from those they had been recruited for. As their careers wore on they frequently took on new responsibilities and let old duties lapse. Examining, committees, overseas lecturing, college duties - and private practice - came and went, with no agreed change of contract or job description. How was this tolerated and how was it practical?
It was tolerated by administrators, health authorities, and boards of governors because generally the work seemed to be done, because overall the body of consultants was seen to be doing more than might reasonably be expected, and because the consultant body in a hospital was a powerful force, while employers were weak. It was practical because of the army of junior doctors, working unlimited hours, tacitly expected to fill in any gaps left by an absentee consultant.
All this has changed. Management is far more direct and powerful, including the involvement of medical managers as clinical and medical directors. The ratio of juniors to consultants has diminished, and consumer pressure has grown. Yet the expectations placed on consultants have increased: they are expected to have a greater personal input into their work; all the extracurricular activities of examining, committee, and college posts are still needed; and there are new demands for teaching, audit, and management. Trying to fit it all in has put a great strain on most consultants, especially in their later years when they are asked to shoulder the responsibilities of senior professionals with no compensatory reduction in the clinical load. Hence the growing stresses and the trend for early retirement which many have seen as the only way to escape.
Four elements of a job plan review
Monthly plan: Draw up a monthly plan specifying the average number of notional half days or hours spent on a range of tasks - for example, outpatients, teaching, ward work, audit, administration - which covers all the hospitals and sites where you work. It should also include duties outside the trust such as examining, lecturing, or serving on national regional committees.
Weekly timetable: Break this down into a weekly timetable of fixed commitments - for example, Monday morning, Granchester General, ward work, Tuesday afternoon, University of Granchester, lecturing to medical students, and so on.
Agreed objectives: Write down your agreed objectives for the year - for example, establish new rheumatology clinic at Granchester Royal Infirmary, establish teaching programme for senior house officers.
Statement of available resources: List the facilities and staff available - for example, operating theatre availability, numbers and grades of both medical and non medical staff.
Short of doctors
We thought this was both regrettable and undesirable. We are so short of doctors in Britain that we cannot afford to lose anyone capable of doing competent clinical work. Early retirement - or simply shirking - only increases the load on those who remain. Retirement is not always good for the individual - the sudden change from a busy, over full professional life to one of complete leisure can be difficult and unsatisfying. Even those who find work on boards and tribunals or as a locum often find themselves missing the corporate life of a hospital in which they have been a senior and respected figure.
Job plan is the solution
The college believes the solution lies in the job plan. Every consultant today should have a job plan, and it is supposed to be discussed annually with a senior manager. In most trusts this has not happened effectively. Consultants initially feared that the job plan was a device to restrict opportunities for private practice, lecturing abroad, or even having a haircut. Managers, in their turn, were apprehensive of possible confrontation if they questioned the consultants' use of their time. We know these fears are exaggerated and addressed the report to consultants and managers. Physicians should not be afraid to identify all their professional obligations - not just clinics and ward rounds - but teaching, examining, committee work, and even private practice.
Managers need to understand that many things are rightly expected of consultants outside the boundaries of the trust, and that the NHS has an obligation to ensure that they are done - and that the trust gets kudos from having its employees involved. If we can reduce the mutual suspicion reasoned discussion can take place and the consultant's career can develop. This is especially important for consultants in their later years, from about 55 onwards, who may want to concentrate activity on the particular skills developed over the years and perhaps reduce the overall time commitment.
In case it is beginning to look as though we are trying to turn doctors into complete compartmentalised consultants with a rigid timetable, I must point out that the first part of the report is all about professionalism, which has acquired a rather tarnished image. We realise that doctors as professionals are self motivating and self regulating and need to accept the responsibilities as well as the privileges this brings. We ask managers to understand that too. There is nothing unprofessional about a properly designed job plan.
Death of the firm
Our other concern was that many consultants have felt isolated as junior doctors have become fewer, rotated faster - and if that sounds as though they are roasting on a skewer I'm sure we all know that feeling - and worked shorter hours. This has resulted in the death of the firm. The solution is for consultants to create new sorts of teams to replace it. Doctors should be more willing to collaborate closely with colleagues, even in a different hospital, sharing not only the on call duties, but also the teaching and administrative tasks. With a bit of thought and imagination collaboration can spread outside medicine and into nursing and administration. The artificial straitjackets placed on all health, managerial, and administrative staff are being removed, and much non clinical work can now be taken on by non medical colleagues at many levels - we must make sure that we make good use of this new freedom.
Change is unsettling
Change is always unsettling, and it has been particularly trying for a group of hard pressed but conservative professionals, practising in a style dictated by tradition. The recent changes are here to stay and more may follow, so if we are to retain our professionalism and the respect of patients, managers, and practitioners we must respond imaginatively and positively. Our report points the way forward.(1)