Osborne and Craft duologue:
relative values
Dr Jonathan
Osborne’s open letter to Royal Colleges’ presidents has roundly
denounced the Royal Colleges in his analysis and perception of their
acquiescence to Government and the Postgraduate Medical Education and
Training Board (PMETB) (1 ). He declares the Government’s Modernising
Medical Careers in implementing post-foundation medical training is
’not in the best long-term interest of either patients, future
consultants, general practitioners or the royal colleges’; that it is a
‘manpower planning disaster from which from which neither Government or
colleges emerge with distinction’; that, informally, doctors allude to
Royal Colleges as ‘irrelevant drinking clubs, whose officers only seek
baubles of state, occasionally bestowed for keeping the profession
quiet’.
Osborne pleads with
the Royal Colleges to prove him wrong by blocking the current reforms
to postgraduate training. He makes a compelling case and we cannot
stress strongly enough how vital it is to read his position paper. It is
a model of lucidity, concision, concern for patients’ and our
profession’s future.
One of his important
points is that the inception of the PMETB, under control of the
Secretary of State was deliberately designed to allow politicians to
change the training of doctors at will which he views, and it is
difficult to disagree, as pernicious and he deplores Modernising
Medical Careers proposal to abolish senior house officers SHOs and
create ‘seamless’ training.
This Society’s
decision to support Osborne was taken following careful consideration of
his tightly argued compelling case and, we submit, the less than
persuasive riposte/response to it by Dr Alan Craft in his capacity as
chairman, Academy of Royal Medical Colleges (2 ). Craft begins his
defence by claiming that ‘methods of training which were appropriate 25
years ago are less so now’. Apparently, he fails to appreciate that
changes in training have been occurring, albeit more incrementally, over
the past 200 years or more and he cites ‘team changes’ (without clear
evidence base) as supporting swingeing upheavals for postgraduate
training. He opines ‘that medicine has become so vast that no single
person can be expected to know everything’. Our view is that this has
been ever thus; that each generation of doctors in its prime tends to
feel this way. It is no more true of today than 30 years ago. To suggest
otherwise is to misunderstand the history of medicine and its
development. Change has been the only constant in the evolution of
medical practice. As a professional system attempting to cope with it in
the interest of best patient care medical graduates in these islands
have evinced an honourable, widely respected, record both at home and
abroad.
Craft declares we
need doctors ‘who are fit for purpose’ in’our pressurised NHS’. Few
frontline medical practitioners now see the currently dystopian NHS as a
national health service ‘fit for purpose’. If any person, general
public or professional, thinks otherwise, then a read of outspoken MP
Boris Johnson There’s nothing national about our National Health
Service will assist in correcting any vision defect (3). More likely
observers marvel that doctors and other clinical staff still function in
treating patients despite politically driven state PFI, ECRs, targets,
stars and independent sector treatment centres. It appears to us that
attempting to train doctors fit for NHS purpose smacks of an overly
political policy purpose and in doing so poses an ethical problem for
the profession.
Craft selects the
specialty of urology to illustrate what he perceives as a manifestation
of modern changing practise and sees it as a sampler unique to our
times. He may, of course choose to believe this. Evidence please! We
aver it is not and thoughts of re-inventing the wheel spring to mind.
Similarly, he makes assertions about novelty of team working somehow
suggesting this has not happened in past decades. We strenuously
contradict this but would add that problems in relation to who leads the
patient treatment team have damaged holistic patient care.
In the specialty of
psychiatry attention has been drawn by general practitioners to patients
being ‘referred into a void’ because they are expected to refer
patients to a ‘team’ rather than to a named consultant. The patient may
thereby not be properly assessed or even be seen by a consultant and
therefore the family doctor receives no medical report. As a result,
Raine et al, consider that not only are patients disadvantaged but GPs’
own ongoing training in this field has been degraded (4). This is but
the tip of an iceberg problem related to fashionable blindness about
proper leadership and who leads. It is not unrelated to confusion in
some minds (not that of most doctors) about the difference between
authoritive leadership and authoritarianism . The latter is
unacceptable, the former essential in any effective human group
organisation. Otherwise chaos is encouraged. We submit that doctors
remain, by their training depth, breadth and experience, the sapiential
leaders in clinical practice. We suspect the man on the Clapham omnibus
thinks the same. Doctors value and respect the contributions of other
team members and Government has formally reaffirmed hospital senior
doctor’s centrality when it endorsed ‘…the key role of consultants in
the NHS in terms of their 24 hour responsibility for patient care. It is
they who are the leaders of clinical teams, responsible for all aspects
of the clinical care of the patients under their charge’ (5).
Craft states, again
without supporting evidence, in his attempt to buttress the need for
changes in training, that medical students today are ‘more inquisitive
than their predecessors’. Even if such, somewhat sweeping assertion,
were true (and we believe it is not) both undergraduate and postgraduate
training can surely satisfy, as it has ever done, the thirstiest of
young minds exploring the frontiers of medical practice in its perennial
spectrum of clinical, teaching, research and healthcare developments.
Croft affects to
shrug off Osborne’s accusation of being ‘led by Government’ by claiming
that they (Royal Colleges) ‘are taking a leading rôle’. But this is
immediately undermined by his then referring to these ‘inevitable
reforms’ and further declaring ‘we do not necessarily agree with all the
pressure put upon us’ – still in the context of Government. His attempt
to deny the primacy of Government pressure in driving the changes in
medical education is feeble rather than compelling. His assertion that
they justify seismic rather than organic, incremental changes in
postgraduate training and that such changes ‘must proceed quickly’ is at
best speculative and at once supports Osborne’s plea to halt them now.
To proceed quickly with such profound changes to the profession’s
development would appear to be the last thing medical education needs at
present if there is to be some degree of stability.
Craft cites European
Working Time Directive (EWTD) as another supporting reason for his
advocated changes. There can be few doctors who do not see such EU
imposed change as both detrimental to medical training and patient care
continuity. Croft’s response to Osborne’s pointing out that training
hours have dropped perhaps 50% with the EWTD is to agree that operative
time has been dramatically reduced. But rather than any suggestion on
Craft’s part of therefore legitimate Royal Colleges’ robust and rational
opposition to such anti-training, anti-patient measures there appears
instead mere craven accommodation to it. That it is nakedly politically
driven cannot but be obvious to any reasonably informed onlooker.
Responsible medical
pressure on Government by a vigorous, confident and even minimally
supposedly self-regulated profession should surely decide this an
item to be opposed by invoking the EU ‘subsidiarity’ Home Affairs
doctrine for individual countries limited self –determination (6). It is
difficult to envision an issue more relevant in this context, that is
too important to be left to politicians alone. Is he aware that when the
General Medical Council was created in 1858 Government regulation for
control of medical standards was still unacceptable to the average
Englishman as a self-regulatory body it was not done to benefit doctors
but rather it appears that even then the public of the day did not trust
politicians with such control over doctors and medical services (7).
Croft admits that
‘it might seem from this reply that medical Royal Colleges are being
compliant ‘in a government policy to deliberately remove their centuries
old setting and maintaining standards of both training and specialist
practice’. He goes on to say nothing could be further from the truth.
But to us the very nature and content of his attempted defence do more
to support than contradict that charge of compliant.acquiescence which
he denies.
In fairness to Craft
he has not raised that politicians’ chimera that since Shipman the
public no longer trusts the medical profession; that this justifies the
headlong rush into swingeing medical training and practice changes .
That this is a nonsense is amply illustrated by the Committee on
Standards in Public Life recent finding that just 23 per cent of people
surveyed trust minister to tell the truth: family doctors rate 93 per
cent and head teachers 84 per cent (8).
Further support, if
such were indeed required, for a moratorium if not cessation, on
Modernising Medical Careers politically driven proposals, is the
observation that never before has the near-monopoly provider system of
healthcare to the nation, the NHS, been so obviously unfit for purpose
and in such a state of chaos as Government piles change upon change with
alarming acceleration and cost to the taxpayer.(3) This has happened as
central Government distances itself from local health service provider
problems caused largely by central government flirtation with
independent sector experiment and other interference..
We strongly endorse
Osborne’s position and plea. ...
1. Osborne J. Modernising medical
careers: an open letter to the Royal College Presidents. J R Soc Med
2006;99:56-7
2. Craft A. Modernizing medical careers:
a response from the Academy of Medical Royal
Colleges. J R Soc Med 2006;99165-7
3. Johnson B. There’s nothing national
about our National Health Service. The Daily Telegraph Aug
31,2006;p24
4. Raine R, Carter s, Sensky MD, Black N.
‘Referral into a void’:opinions of general practitioners and others on
single point of access to mental health care. J R Soc Med 2005;98:153-7
5. Working for Patients.NHS review
working paper 7. NHS consultants; appointments, contracts and
distinction awards. P3. London:HMSO, 1989
6. Bercow J. Subsidiarity and the
illusion of democratic control. [http:www.brugesgroup.com/mediacentre/index.live?article=192].
Accessed 2 September 2006
7. Brand J. Doctors and the State.
Maryland: The Johns Hopkins Press:1965
8. Leader.
Ratting away. The Daily Telegraph Sept 16,2006,p24
****************************************
Dr Dermot Ward,
Chairman, Society of Clinical Psychiatrists
4 Jubilee Terrace
Chichester West Sussex PO19 7XT Telephone 01243778716
E-mail:dermot.ward@talktalk.net |