Medical Manpower and Training
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818 MEDICAL METAL DETECTORS ARE NOT NEW SIR,-Although handy, Mr Leicester and Dr Williams’ use (Aug. 1, p. 232) of a metal detector to localise foreign bodies (i.e., endoscope tips) is not novel. Alexander Graham Bell used a battery, two coils of insulated wire, a circuit breaker, and a telephone to locate the assassin’s bullet in President Garfield’s abdomen in July, 1881.1 Interest in the telephone-cum-metal-detector was shortlived. The "new rays" of Wilhelm Roentgen supplanted it in 1895. However, given the cost-benefit and cost-effectiveness studies now in vogue, coupled with the attractiveness in some quarters of remote telediagnosis, perhaps the entire question should be reopened. Departments of Medicine and Pediatrics, Georgetown University School of Medicine, Washington, D C. 2007, U.S.A. WILLIAM R. AYERS 1. Roth N. Tracking by telephone: Locating the bullet in president Garfield, 1881. Med Instrum 1981, 15: 190. Commentary from Westminster Medical Manpower and Training AT present, many patients in N.H.S. hospitals never actually meet their consultant and that is "clearly unaccept- able", in the view of the all-party back-bench Commons Select Committee on Social Services. After six months’ investigation into medical manpower and training, including evidence from D.H.S.S. Ministers, administrators, medical schools, doctors’ representatives, and other interested bodies, the Social Services Committee concludes: "The consultant who carries responsibility for the patient’s care should be fully aware of the patient’s circumstances, the diagnosis, the course of treatment and the patient’s reaction to that treat- ment, even if the consultant has not made these decisions personally. It follows that in most hospitals and most specialties there should be an increase in the number of con- sultants and the number of junior doctors." The report talks of inadequate recruitment to many specialties, notably psychiatry, geriatrics, pathology, and community medicine. In many hospitals staff have to work too hard. Short-term solutions have led to the creation of too many junior posts, the appointment of large numbers of overseas doctors, and thus to dilution of standards of supervision, "blurring" of clinical responsibility, and "grave and continuing distortion" of the medical career structure. Some older consultants have resisted corrective measures through unwillingness to lose their tradition of plentiful junior support; health authorities have been attracted by the apparent cheapness of employing juniors; overseas doctors have been willing to accept junior posts because of the supposed training content. But as a result the real cost of doctors’ salaries has risen "significantly" over the past ten years "largely to’ fuel the increase in juniors". A service with more consultants might in fact be cheaper, the committee thinks. It would result in better productivity, improving standards of care, and would probably reduce waiting lists and the costs of continuing sickness. Patients were entitled to be treated by trained specialists (that is, consultants) and general practitioners. The purpose of junior appointments was to provide training, not service. If there were more consultants, movement through the training grades would then be determined by the doctor’s aptitude, not by the chance availability of scarce senior-registrar and consultant posts. The grade of senior house officer, the report suggests, should be frozen at its present level, while the Government urges health authorities to increase consultant numbers. Unemployment among doctors is negligible at the moment. But failure to correct the career structure will lead to bottle- necks and unemployment during the training period. Every doctor should have some postgraduate training with old people, babies, and children, and mental illness and distress, the report suggests. The number of training places in each specialty should reflect the demand for partient care in these specialties. A system still had to be found to correlate those needs in the community with the output of the medical schools. Training should also take more account of the needs of women doctors and doctors with domestic commitments, as should career posts. The report comes out against overtime payments to con- sultants and extra-duty payments to doctors, which "merely provide some compensation for an excessive workload that should not occur". With the change of emphasis proposed by the report, it is conceded that consultants will have to undertake more on-call emergency work, which should fall mainly on the younger members of the team. The committee insists that in the interests of patients, no doctor, junior or consultant, should have to do a full day’s work after coping with emergencies during most of the previous night. Nor, the report adds, should it always be necessary for consultants to move from one job to another to get promotion. The existing distinction award scheme may have to be expanded if a con- sultant-based scheme is to become the norm. Consultants’ contracts should be held by district health authorities, but the region should control the deployment of consultants to ensure that district medical planning conforms with national agreements. The report also comes out against the creation of a new subconsultant grade and a hospital practitioner mark-11 grade. Both have too many disadvantages, and would undermine progress towards a consultant-based system. Meanwhile, in next year’s planning guidelines the D.H.S.S. should draw up a plan for increasing consultant numbers. The Department should also publish, through the medical press, the results of preliminary studies on how to organise a consultant-based service. The problems discussed in the report "are pressing, and in no sense insoluble". The committee points out, however, that their solution will require that the level of growth money in the N.H.S. should be increased sufficiently, both for the process of this change in career structure to be rapidly accelerated, and for other high priority areas to be adequately funded. The D.H.S.S. itself is now studying the report, and intends to issue a response in due course. Liberals Would Spend More on Health In any Liberal/Social Democrat administration after the next general election, the Liberals would press for the country to spend a substantially higher level of national income on health, according to the party’s health spokesman, Lord Winstanley, speaking at the Liberals’ annual assembly at Llandudno. A large increase in such spending would only take Britain up to the general level of most of our European neighbours. "If such spending meant more taxes we would still do it. The voters would vote for it." He attacked the "lunacy" of Government cuts in spending which actually cost money. By cutting home-helps and services to the elderly and the chronic sick, the Government was forcing more
Transcript of Medical Manpower and Training
818
MEDICAL METAL DETECTORS ARE NOT NEW
SIR,-Although handy, Mr Leicester and Dr Williams’ use (Aug.1, p. 232) of a metal detector to localise foreign bodies (i.e.,endoscope tips) is not novel. Alexander Graham Bell used a battery,two coils of insulated wire, a circuit breaker, and a telephone tolocate the assassin’s bullet in President Garfield’s abdomen in July,1881.1 Interest in the telephone-cum-metal-detector was shortlived.The "new rays" of Wilhelm Roentgen supplanted it in 1895.
However, given the cost-benefit and cost-effectiveness studies nowin vogue, coupled with the attractiveness in some quarters of remotetelediagnosis, perhaps the entire question should be reopened.Departments of Medicineand Pediatrics,
Georgetown University School of Medicine,Washington, D C. 2007, U.S.A. WILLIAM R. AYERS
1. Roth N. Tracking by telephone: Locating the bullet in president Garfield, 1881. MedInstrum 1981, 15: 190.
Commentary from Westminster
Medical Manpower and TrainingAT present, many patients in N.H.S. hospitals never
actually meet their consultant and that is "clearly unaccept-able", in the view of the all-party back-bench CommonsSelect Committee on Social Services. After six months’
investigation into medical manpower and training, includingevidence from D.H.S.S. Ministers, administrators, medicalschools, doctors’ representatives, and other interested bodies,the Social Services Committee concludes: "The consultantwho carries responsibility for the patient’s care should befully aware of the patient’s circumstances, the diagnosis, thecourse of treatment and the patient’s reaction to that treat-ment, even if the consultant has not made these decisions
personally. It follows that in most hospitals and mostspecialties there should be an increase in the number of con-sultants and the number of junior doctors." The report talksof inadequate recruitment to many specialties, notablypsychiatry, geriatrics, pathology, and community medicine.In many hospitals staff have to work too hard. Short-termsolutions have led to the creation of too many junior posts, theappointment of large numbers of overseas doctors, and thusto dilution of standards of supervision, "blurring" of clinicalresponsibility, and "grave and continuing distortion" of themedical career structure. Some older consultants haveresisted corrective measures through unwillingness to losetheir tradition of plentiful junior support; health authoritieshave been attracted by the apparent cheapness of employingjuniors; overseas doctors have been willing to accept juniorposts because of the supposed training content. But as a resultthe real cost of doctors’ salaries has risen "significantly" overthe past ten years "largely to’ fuel the increase in juniors". Aservice with more consultants might in fact be cheaper, thecommittee thinks. It would result in better productivity,improving standards of care, and would probably reducewaiting lists and the costs of continuing sickness. Patientswere entitled to be treated by trained specialists (that is,consultants) and general practitioners. The purpose of juniorappointments was to provide training, not service. If therewere more consultants, movement through the traininggrades would then be determined by the doctor’s aptitude,not by the chance availability of scarce senior-registrar andconsultant posts.
The grade of senior house officer, the report suggests,should be frozen at its present level, while the Governmenturges health authorities to increase consultant numbers.
Unemployment among doctors is negligible at the moment.But failure to correct the career structure will lead to bottle-necks and unemployment during the training period. Everydoctor should have some postgraduate training with oldpeople, babies, and children, and mental illness and distress,the report suggests. The number of training places in eachspecialty should reflect the demand for partient care in thesespecialties. A system still had to be found to correlate thoseneeds in the community with the output of the medicalschools. Training should also take more account of the needsof women doctors and doctors with domestic commitments,as should career posts.The report comes out against overtime payments to con-
sultants and extra-duty payments to doctors, which "merelyprovide some compensation for an excessive workload thatshould not occur". With the change of emphasis proposed bythe report, it is conceded that consultants will have toundertake more on-call emergency work, which should fallmainly on the younger members of the team. The committeeinsists that in the interests of patients, no doctor, junior orconsultant, should have to do a full day’s work after copingwith emergencies during most of the previous night. Nor, thereport adds, should it always be necessary for consultants tomove from one job to another to get promotion. The existingdistinction award scheme may have to be expanded if a con-sultant-based scheme is to become the norm. Consultants’contracts should be held by district health authorities, but theregion should control the deployment of consultants toensure that district medical planning conforms with nationalagreements.The report also comes out against the creation of a new
subconsultant grade and a hospital practitioner mark-11 grade.Both have too many disadvantages, and would undermineprogress towards a consultant-based system. Meanwhile, innext year’s planning guidelines the D.H.S.S. should draw upa plan for increasing consultant numbers. The Departmentshould also publish, through the medical press, the results ofpreliminary studies on how to organise a consultant-basedservice.
The problems discussed in the report "are pressing, and inno sense insoluble". The committee points out, however,that their solution will require that the level of growth moneyin the N.H.S. should be increased sufficiently, both for theprocess of this change in career structure to be rapidlyaccelerated, and for other high priority areas to be adequatelyfunded. The D.H.S.S. itself is now studying the report, andintends to issue a response in due course.
Liberals Would Spend More on Health
In any Liberal/Social Democrat administration after thenext general election, the Liberals would press for the
country to spend a substantially higher level of nationalincome on health, according to the party’s health spokesman,Lord Winstanley, speaking at the Liberals’ annual assemblyat Llandudno. A large increase in such spending would onlytake Britain up to the general level of most of our Europeanneighbours. "If such spending meant more taxes we wouldstill do it. The voters would vote for it." He attacked the
"lunacy" of Government cuts in spending which actuallycost money. By cutting home-helps and services to the elderlyand the chronic sick, the Government was forcing more
