Intended for healthcare professionals

Letters Standards in the NHS

The “curse of the registrar”

BMJ 2012; 345 doi: (Published 18 September 2012) Cite this as: BMJ 2012;345:e6039

Re: The “curse of the registrar”

We read John Walshe’s account of his experiences in being handed from registrar to registrar with sympathy and recognition. (BMJ 2012;345:e6039) Failure to provide continuity of care, so that a succession of inexperienced, junior members of the outpatient team handle patient interactions, is the single biggest source of dissatisfaction expressed by our members.

As John Walshe observes, a production-line, or first-cab-off-the-rank approach to outpatient care tends to result in deteriorating medical standards. Trainees acquire insufficient longitudinal experience to observe what is working on a case by case basis. Nor, for rare conditions like Addison’s, with an incidence of 140 per million, can they expect to gain a critical mass of experience with similar patients, sufficient to extrapolate from one case to another. (Lovas & Husebye, CE (Oxf). 2002 56(6):787-91)

Access to sufficient medical experience is particularly important for hypoadrenal patients, whose acute steroid-dependency has been been known to result in death within five days of running out of medication (see An untimely death, at Or within hours of under-treated adrenal crisis (See, for example, Hahner S et al, EJE 2010 162 597-602).

Inadequate consultant access is a source of frustration for the registrar and potentially compromises patient safety in acute conditions such as steroid-dependence. How to address this challenge, which is widely acknowledged to be a construct of contemporary NHS management systems and processes?

Manufacturing is unlikely to be a smart model for healthcare to emulate, unless you contemplate the Miele philosophy of a 20 year guarantee on after-sales servicing and spare parts. Yet by production-line standards, tertiary care within the NHS has much to aspire to. Modern manufacturing sites usually work with defect rates of considerably less than 1%. In the US software industry, defect rates are typically benchmarked at less than 7 per thousand. In this context, we note that comparative information on infection, readmission and similar indicators of clinical performance are not usually available for the private sector healthcare providers that patients are increasingly being encouraged to opt for. (For publicly available NHS performance data see, for example,

To encourage higher standards of clinical care for steroid-dependent adrenal patients, the Addison’s Disease Self-Help Group encourages the development of tertiary, regional centres of expertise in adrenal medicine. Our members value the greater depth of clinical expertise available at large teaching hospitals, and are increasingly motivated to seek treatment at centres that can offer:
• Training in self-injection and the provision of injection materials
• Day curve monitoring of hydrocortisone replacement therapy
• Specialist endocrine nurse support.

Yours sincerely,
Katherine G White (Chair), Noel Hawks (Injection education co-ordinator), Deana Kenward MBE, (President), Alison Mainwaring (Nursing awareness coordinator), Phil Stevens (Ambulance awareness coordinator)
Addison's Disease Self-Help Group

Competing interests: No competing interests

26 September 2012
Katherine G White
Noel Hawks (Injection education co-ordinator), Deana Kenward MBE, (President), Alison Mainwaring (Nursing awareness coordinator), Phil Stevens (Ambulance awareness coordinator)
Addison's Disease Self-Help Group
PO Box 1083, Guildford GU1 9HX,