Named consultant for hospital patients will end culture of “brief encounters,” says England’s health secretary
BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g1104 (Published 24 January 2014) Cite this as: BMJ 2014;348:g1104All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
I agree with Mr Hunt's view about named consultants and the lack of such an arrangement leading to a diffusion of responsibility. The organisation of non-surgical care in hospitals has been modeled around the terms of the contract of Consultants, nurses and junior doctors. The requirement of a named consultant requires a sea change in attitudes and pathways and processes which would take a huge upheaval to reorganise. A named Consultant model would also warrant a named nurse, therapists and juniors if we are serious about continuity in a holistic sense. Till recently, re-organisation happening outside secondary care had drained a lot of resources but this internal re-organisation could be done with the degrees of enthusiasm and flexibility that anyone working in healthcare should possess. It is certainly a priority.
Competing interests: No competing interests
Jeremy Hunt's speech at St Thomas' hospital calling for a new model of care in the NHS to tackle the "fragmentation of care experienced by patients in hospital" was based on evidence from a US study showing reduced average length of stay when patients have a named whole stay doctor (1). Why does it seem to take us so long to learn a lesson from history which has been evident for so long?
In 1964 the (in) famous case of the murder of Kitty Genovese was reported in the
New York Times, where a young woman's murder was witnessed by up to 38 people and yet no one helped or indeed called the police (2). This lead to the study of the sociopsychological phenomenon of what would become known as diffusion of responsibilities, also known as the bystander effect. This effect is seen when an individual believes that other people will or should intervene in a situation and therefore relieves themselves of the responsibility to take action. The more people who are present at an event, the less likely an individual will offer help, with further exacerbation by giving the individual anonymity.
Out of hours working, with a number of individuals all vaguely responsible for patient care replicates the perfect environment for diffusion of responsibility. We are concerned that an unintended consequence of Seven-Day Working, which may involve a Consultant taking care of other Consultants' patients, is that there may be a reluctance to intervene once a course of action has begun. The individual responsible for the care of a patient should always be clear and accessible to all involved in that patients's care. This call to individualise responsibility to a doctor is a welcome (if somewhat late) step forward in improving patients' hospital stays.
1. BMJ 2014;348:g1104
2. Gansbery M. Thirty-eight who saw murder didn't call the police. New York Times, March 27, 1964
Dr S J McNulty MB ChB FRCP FHEA
&
Dr P Williams MB ChB FRCP
Consultant Physicians
Competing interests: No competing interests
Re: Named consultant for hospital patients will end culture of “brief encounters,” says England’s health secretary
Oh Jeremy. You are very very young. Otherwise you would have known that ever since hospitals began with consultants, the consultants were consulted - by the resident medical/ surgical officer. The RMO/ RSO might have been an SHO (senior house officer) or a middle grade registrar. Or, in some hospitals, a Junior Hospital Medical Officer. The JHMOs abounded in geriatric, psychiatric, chest, mental subnormality hospitals but also, sometimes, in acute specialities. They were there, for life, as it were. They did not mess around with post-grad exams, didn't hop from hospital yo hospital. They provided continuity of care.
In those days, the consultant's name Was at the head of the bed and at the foot of the bed.
In those days, the GPs would refer the patient to a Named Consultant, a consultant of HIS choice. I am talking about acute specialities. I suppose the Royal College presidents are too young to know all this. Otherwise they would have told you that the old wheel is still there in the farm yard. You just need to clean it. Maybe the modernisers of medical careers should have remembered that the JHMOs grade was slaughtered without good reason. Likewise, the SHMOs. They were as good as the consultants and they were there when the consultant was not available.
Now to the nurses. And named nurses. Some years ago I was in hospital for a two day sojourn. A Named Nurse interviewed me for about an hour. She was charming. As she was leaving, I thanked her and said I hoped to see her again. Oh no, she said, I am off to ski as part of RAF training exercise.
Close down all BSc Nursing courses. Bring back "nurse cadets", the PTS (preliminary training schools), from age fifteen. Two years later send them to the wards, year 1, then 2, then 3. Get the registrars to teach them. At the end of three years, examine them and make them SRNs. Staff nurses.
Nursing 2000, Graduate nurses. Do they ever know what and how much the patient on the ward has eaten? Have they learnt how you look for DVT? Do they know how to pass a catheter? To make a bed?
Now I shall have a sip of cold water. A chota peg would be better but I am reluctant to burn my insides.
Competing interests: Memories of a bygone age