The visitor consultant: a new disturbing grade!

Dr Dermot J Ward

On November 16, 2000, The Daily Telegraph carried a special report on the Commission for Health Improvement's inquiry into Garland's Hospital run by North Lakeland NHS Trust in Carlisle, Cumbria.  There was a catalogue of "degrading and cruel" practices because of a "systematic failure of management", claimed the report. Many readers will be aware of the quite dreadful abuse suffered by those unfortunate elderly mentally ill patients.  The trust's chairman was deservedly dismissed. Nothing can or should be said to whitewash this whole tragic situation for patients and their loved ones. 

There was also strong criticism of the consultant psychiatrist responsible for those patients allegedly abused. He responded, perhaps surprisingly, that he was made to feel like a visitor on his own ward and that he was not aware of the abuse. But the commission said it was "deeply disturbed" by the consultant's "lack of awareness" and "passive acceptance" of being treated in this way.  "This reflects an inadequate sense of medical accountability in so senior a figure." To my best knowledge no further action was taken against him/her.

But if the Commission's observations on the consultant are correct it behoves us to look more closely at his defence: that he "felt like a visitor on his own ward".  The Commission is right to emphasise consultant accountability.  Working for Patients (1989) reiterated...  "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."  It could hardly be clearer. It is not the "Team" that is called to account.

There can be no retreat for a consultant into those weasel words that attempt to diffuse responsibility with "we the team are all responsible". But in the NHS the most basic tenet of general management systems theory - that those charged with leadership accountability and responsibility must also be given commensurate authority to enable them discharge their duties effectively - is lately more honoured in the breach than the observance. And that has not grown like Topsy.  Essential authority has been systematically undermined by politically inspired initiatives, notably by Griffiths NHS management report (1983). Entrenchment of this erosion was solidified by Working for Patients. The accountability and responsibilities remained unchanged, as needs must. No other professional group within the medical team has the necessary training, experience and skills to justify being entrusted with such leadership, accountability and responsibility.

Prior to these changes, secondary health services, their preservation and development, were essentially led by doctors in the NHS working in concert with politicians and administrators. But since those deliberate government-driven changes undermining that essential authority of doctors there has been a massive drop in staffed mental hospital bed numbers.  As an example between 1987 and 1994 there was a reduction of 37% (from 67, 000 to 42,000) even in the teeth of local and national consultant opposition. Today, with trust secrecy and consultant gagging (which Health Minister Alan Milburn promised when in opposition to reverse if elected in 1997 - surprise, surprise, he didn't), we can but guess. Unlike many other specialties which have made dramatic treatment strides since, say, the 1960s, which might justify such bed depletion more readily, no such magnificent advances have happened in psychiatry.  Improvements, yes, refinements, yes, but none sufficient to justify those stonking bed cuts. This would never have happened prior to the "new improved NHS".  Recommended bed norms previously laid down by the Royal College of Psychiatrists which had been agreed with, and honoured with DoH were dismissed as an irrelevance when consultants objected.

No small wonder that complaints against unfettered care in the community rose to a pitch that even the last Government's health minister Peter Lillie arose as from a Rip van Winkle slumber to announce finally that that blindly pursued policy had been disastrous for psychiatric patients.  Public complaints and inquiries have mushroomed since but staffed hospital bed numbers have not.  Yet again, consultants were targeted, in a carefully orchestrated manner by government as patronising, arrogant, and the blood cry went up that doctors must be more prepared to work in teams. Yet, I have never encountered a consultant whatever his/her specialty, who did not realise the importance of the medical team in day-to day clinical work.  But such exhortation repeated with menaces suggested that other team members were undervalued by doctors.  Only a fool would pursue such a course so patently not only against patients' interest but of involved consultants.

However, elevating the "team" and somehow suggesting that all team members were equal in decision taking in matters of clinical care, has served further to deny essential consultant confident authority in the discharge of his/her responsibilities.   A conflation of authoritative (necessary) and authoritarian (unwelcome and unwanted) by government which never hesitates to emphasise consultant accountability when blame arises, has been indeed a deeply disturbing trend.  Doctors are, understandably, their most penetrating policy critics. 

Introduction of titles such as "ward manager" for what used be ward sister or charge nurse: nurse 'consultant', 'consultant' clinical psychologist; the re-designation of patients as 'clients' by freebooting nursing staff on some wards, without so much as asking the appropriate responsible consultant views on the general desirability of using such titles in the NHS, further muddies and muddles leadership and responsibility waters. There has, too, been a subtle attempt, to devalue doctors by suggestion that the "medical model" is insufficiently holistic. Truth to tell, doctors' training and experience, the medical model, equips them in the bio psychosocial dimension that offers the greatest potential for holism of any of the allied-to- healthcare professionals.  Of course, appropriate leadership does not eschew delegation but it does explain why politicians and the judiciary continue to look to doctors when matters of medical accountability and responsibility arise.

Politically generated diminution of doctors' authority is a dangerous game, played at patient-care cost. Being a visiting consultant in a hospital is one thing. Being a "visitor" consultant is quite another. It is an untenable position for a medical team leader.

UK