Education And Debate

Rethinking Consultants: Time for change in traditional working practices?

BMJ 1995; 310 doi: (Published 25 March 1995) Cite this as: BMJ 1995;310:788
  1. John Bailey, senior managera
  1. a Audit Commission, London SW1P 2PN

    Consultants in Britain are under pressure to change the way they organise their work. Many rely on formal, but unwritten, rules and a culture of “learning by doing.” Unlike their counterparts in Sweden, they are often not well integrated into the management systems of their hospitals. The result is wide differences in the NHS workloads of individual consultants and, for a minority, conflicts of interest with their private work. The training received by junior doctors varies because it is largely left to individual consultants. Clinical directorates should provide a more effective mechanism for consultants to influence trust policies and for consultants to implement these policies. Consultants must not only recognise the need for change but also seize the initiative.

    Consultants are under pressure worldwide from changing health care technology, patient expectations, and the demands of governments for greater efficiency. In the United Kingdom the government's policy on hospital medical staffing is to increase the level of direct patient care provided by consultants.1 Many consultants have changed their clinical practices in response to these pressures, but the way in which they organise their work has changed much less. It is based on a long tradition of medical hierarchies with formal, but unwritten, rules about who should do what and a culture of “learning by doing.”

    The role of the consultant has two essential characteristics: autonomy and a position as leader of the “consultant firm.” Increasingly, both are resulting in significant problems which ought to be addressed.

    Consultant autonomy

    Consultants carry a heavy burden of responsibility for patient care. They are legally responsible for all aspects of their patients' medical care, irrespective of the extent to which they personally deliver the care. Clinical freedom—the concept that individual doctors must base their decisions about patient care on their own judgment about what is best …

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