Consultants should be checked up on, says commission

BMJ 1995; 310 doi: (Published 18 March 1995) Cite this as: BMJ 1995;310:687

Consultants in Britain should be monitored for their attendance at outpatient clinics and operating theatres, said the Audit Commission this week. It said the though most consultants “need have nothing to fear from such monitoring,” the data could be used in disciplinary procedures.

The commission surveyed 11 hospitals and sent questionnaires on working practices to 1100 doctors, of whom 655 responded. Its report finds that private work is done at the expense of NHS commitments: the quarter of doctors who do most private practice carry out less NHS work than their colleagues.

“If anything the results are likely to be an underestimate of the trade off between NHS and private work,” warns the report. “For those so inclined, it is easier and less visible to find the time for private practice by cutting back on aspects of NHS responsibilities other than operating sessions.”

Since 1991, district health authorities and trusts have been responsible for agreeing job plans with consultants that detail their fixed commitments. The commission found that some hospitals did not have job plans and that where such plans existed they were not monitored. The commission surveyed 43 consultants' attendance in operating theatres and outpatient clinics and found that only just over half attended all their fixed commitments. Non-attendance due to leave or cancellation outside the consultants' control was not included in the analysis.

The report is critical of the way in which doctors work. There are 55000 doctors in British hospitals, who account for £2000m of NHS expenditure. But while the demands of the service have changed—patients spend less time in hospital and require more care during that time—doctors have not changed their work patterns. “Despite some broadening of firms and sharing of junior doctors, many consultants still practise as individuals rather than as part of a team and the roles of junior grades and the culture of the medical hierarchy remain essentially the same,” says the report. “Doctors' working arrangements have not adapted fast enough to the rapidly changing environment in which they work.”

The commission argues that “the number and mix of staff are more related to custom and practice than to the needs of either patient care or medical training.” It says that junior doctors should have job descriptions and guidelines on who should do what tasks. In some hospitals senior house officers were carrying out most of the operating sessions without senior staff, and overall they ran one in five outpatient clinics.

The report is clear that teams are preferable to firms—workload can be spread more fairly, and juniors can have better access to consultants at all times. It says that shift work is more effective for providing emergency cover and that senior doctors should be present at busy on call periods such as late morning and evening. “The most junior staff are usually first on the scene in emergencies and sometimes have too much responsibility given their level of training,” it says.

Postgraduate deans, who are now responsible for half the training budgets of junior doctors, are urged to improve careers advice and, with the royal colleges and trusts, develop structured training. The report finds that while 85% of consultants said that they assessed their junior staff, fewer than half of the junior doctors said that this was the case.

The report calls on the Department of Health to produce guidance on the skill mix of doctors, review the need for national controls on training grades, and increase part time posts.—LUISA DILLNER, BMJ

The Doctors' Tale is available from HMSO book-shops, price £12.

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