A Discriminating View of the Doctors' Staffing Crisis in the NHS

We are going through extraordinary times for the NHS, especially so for doctors. From my perspective, this reflects the effect of not getting it right for everyone from the beginning.

The NHS as a care delivery model is fantastic. Tax funded, free at the point of care delivery, delivered at more or less the same standard across the country. It is so special, no doubt about the model/pathway.

The issue comes when it comes to staffing that delivery model. There was simply no staff at any time to deliver this model. So quite simply, as was always done in British history, the UK looked abroad for resources (the detriment to other countries by this policy is till today ignored by the UK). For healthcare the crucial frontline resource - the doctors were simply imported, poached, stolen (you can choose whichever word you want depending on the perspective) from abroad. India being a country which has medical education delivered in English following a British system of medicine was a natural target. For ages, even till today many IMGs end up as GPs in inner city and deprived areas. But it is the hospital medical hierarchy where the glaring disparity hits you.

There was always a surplus of registrar and senior registrar posts compared to the consultant posts (there was a permanent pyramid). Now that may be a problem in itself leaving people without opportunities. What happened from the mid 1970s onward, the demographics of the pyramid shifted. In the registrar and senior registrar grades there were mixed ethnicity with plenty of IMGs but very few of the IMGs went on to become consultants. The locals were in line for progression to a consultant post barring unforeseen circumstances and the IMGs were to remain permanently as registrars and senior registrars barring unforeseen circumstances, till they retired or died. These were later called staff grades and associate specialists. Name change and plenty of warm talk but the intention and roles remained the same. 


In the late 1980s and early 1990s I have heard numerous that local graduates holding registrar and senior registrar posts stated openly, loudly and clearly that they will put up with difficult conditions and low pay because it is only for a relatively short time before they became consultants. Meaning, that locals will progress on to higher pay and the IMGs will remain on the lower pay. This suited a brilliant care delivery model to be delivered at a low cost using a rubbish discriminatory unjust medical staffing model.


Of course, this strategy would have worked except that more consultants were needed and there were not enough local candidates. By late 1990s early 2000s the system woke up to this and created more medical school places and in my view with the hope that this local - IMG differential would continue. Where it went wrong primarily is that they underestimated the impact of women entering medical school, like most men, most women are excellent doctors but firstly they also want a good lifestyle (in contrast to men who in my view were often married to their careers) and more importantly physiology demands that many women choose to have children. So workforce planning went for a six; more IMGs were needed and the flood gates were opened in the early and mid 2000s. 


You see, now, suddenly, the pay for doctors is thought of as high, suddenly evening and weekends are no longer want to be considered as premium pay time. When medicine was overwhelmingly a white, male profession with IMG men manning the lower ranks these were not issues, doctors pay was relatively high compatible with their education and contribution, weekends were precious. The demographics change to equal number of women and a large number of IMGs and the values change.

The next wrong calculation comes from the fact if UK thinks they can import their way out of this mess. I don't know about other countries but many Indian young doctors are very wary of coming to UK; the training opportunities have increased in India, the economic opportunities have increased in India and lifestyle is improving in India - the exchange rate alone is no longer attractive.

To me it seems that the establishment does not want medicine to be an elite profession as it was when it was white male dominated. This makes it distinctively unattractive. There was always discrimination, there still is; the difference now is that there is FOI, there is corporate social responsibility and transparency. In the past we knew IMGs failed exams but we did not know the numbers, we always accepted that we did not reach the necessary standard, we were expected not to reach the standard, we were brought up being told that we could not reach the standard. None of that bullshit anymore. We know the numbers which are spread immediately all around the world by email, whatsapp, fb and twitter. We are asking questions; does the Indian IMG paeds reg trained in UK and taking the exam in UK have a higher failure rate in the UK version of MRCPaed than the Indian paed trainee who takes the exam in India never having worked a day here? Does the MRCGP International AKT MCQ have a longer time to answer their question than MRCGP UK which puts IMGs at risk of failing a 'purely knowledge exam'? We suspect an adverse use of linguistic bias. We know that Scottish, Irish etc need a grade c in English equivalent to IELTS 6.5 but IMGs need an English standard much higher, yet found fault with their language. We know the students in England do not need English A levels to get into med school. The standard for IELTS for IMGs was not set by administering to a group of local FY2s, it was actually set by an equivalent of a large focus group sitting around a table and deciding what was an acceptable standard; what a marvelous way of standard setting (accompanied by truck loads of stats on why that kind of standard setting was valid, the whole lot I found dubious, okay, to put it politely, it was very highly subjective)

The senior doctors including senior IMG doctors seem to have a distinct mentality that is not quite in sync with the younger doctors and their aspirations. The true cost of discrimination against women, discrimination against IMGs is now biting back.

A fabulous care delivery model designed six decades ago by the local population for the local population in UK did not consider the career prospects of IMGs and did not care that women were not part of the game for a long time are now completely flummoxed when IMGs are waking up and women are demanding a different kind of atmosphere. 


I wait to see if the lessons from past atrocities will be learned, I wait to see if because of the change in demographics medicine will be deliberately made into a lesser profession. I am not optimistic about the people becoming just. Why am I not optimistic? Let us look at the current routes into UK for IMGs - the MTI and the PLAB.


The whole MTI premise is based on getting people into UK to fill in rotas. It would be very difficult to provide any proper training in two or three years; especially when MTI doctors are not deanery numbered trainees for whom there is still to some extent funding for training. When I look around, I find that most new entrants into UK are in rota fodder posts and not in any proper training posts. I am not sure if there are large number of MTI doctors who are undergoing specialised training  (say for instance in pancreatic transplants), I suspect most of them are at SHO and junior registrar levels.

Let us say that a doctor goes back to India after MTI and applies for a job in a corporate hospital in competition with a CCT holder - who will get the job? Let us say an MTI completed doctor applies for a job anywhere else in the world (middle east, australia, etc) what kind of a job will (s)he get on the basis of MTI? Has anyone asked these questions? My personal feeling is that in most of the cases a typical MTI doctor after the completion of the time and leaves UK as per the rules is unlikely to be a strong candidate for any job anywhere in the world (I am sure there will be exceptions to this assumption).


So what is the use of MTI posts? 


The next is PLAB route doctors who more often than not spend years in a variety of non-training posts. My advice to young doctors who come to UK after PLAB process is 'take a formal training post or do not take a post at all in the UK'.


If still doctors from India want to come to UK via MTI or accept a non-training post via PLAB then the only logical reason for that would be to use UK as a temporary staging post to analyse and access opportunities in the rest of the world eg prep for USMLE etc.

UK should stop looking at IMGs as rota fodder. The system should change to provide every doctor who enters UK only formal training posts with the intention of making them a consultant or a GP; there may be some who eventually choose not to practice as a consultant and take up a senior non-consultant post, that would be a matter of personal choice and not a systematic denial of opportunity. This means at junior levels there are only training posts. Well, will this ever happen, I wish it would but I am pretty certain it won't. The system is designed for and habituated to exploitation of the IMGs; that system is unlikely to shock itself by changing even when it faces its own existential crisis.

So unless there is a technological solution there is going to be an ugly muddle impasse in the NHS for a long time to come.

©M HEMADRI

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How to do a ward round

Till recently there were no accepted method, standard, process, protocol or parameters on how a doctor should do a ward round for in-patients. We generally turn up, see the patient, sort problems and when the patient gets better we discharge the patient. In recent times there are emerging opinions which have led to some recommendations on ward rounds.
 
I describe my personal experience of one of the best ward rounds that I had the privilege to be a part of during my training days. I describe the ward rounds of the late Mr Suresh B Desai, Consultant Surgeon, Scunthorpe General Hospital. The following is a tribute to him.

House Surgeons should come in at 8 am and had till 9 am to prepare for the ward rounds (time was defined - nothing woolly there); the job was defined:

- Get an updated list of in-patients including admissions through other consultants emergency takes, outliers and consultation requests from other consultants
- Write in the patient notes the results of investigations or have the investigation results on hand ready to be written in the notes
- Deal with any really dire emergencies where the physiology was really poor

Registrars should come in at 8.30 am and had till 9 am; their job was defined:

- Help the house surgeon deal with dire emergencies if there were any
- Talk to the nurses to identify any issues that arose overnight for the in-patients

Mr Desai would arrive at 9 am to the male ward. If there were any dire emergencies the registrar (and not anyone else) would continue to deal with it. Otherwise the whole team started the ward round. The whole team included the ward sister and the nurse who looks after the patient apart from the house surgeon, medical students if any, clinical attachment doctors if any and other healthcare staff as relevant. What I call a ward round kit followed the team - this included the notes trolley, all investigation request forms, a dictaphone, gloves, gel, stationery (continuation sheets, consultation request forms), some house surgeons used to take canulation trays as well.

Every patient was seen - well that is what a ward round is for.

But what then happened was simply brilliant. 

Everything that the patient needed as a result of the consultant visit was completed before moving on to see another patient.

If a patient needed bloods to be repeated immediately it was done right there in front of the consultant, bloods need to be repeated in the afternoon or the next day the forms were done right there, any other test requests (X-ray, CT, ECG, etc) were done then and there. Any communication with other teams/speciality's consultants/registrars they were bleeped or rung, spoken to or if they were not available a message was left with their secretaries. Letters needing dictation though this was rare was done right there. A canula that needed doing was done then and there. Every work that was generated as a result of Mr Desai's ward round was done in the presence of Mr Desai or if appropriate by Mr Desai himself as soon as it was generated before moving on to the next patient for whom again the same process applied.

This made the ward round quite long. When most other consultant ward rounds took less than an hour (which was reasonable by surgical standards), Mr Desai's ward round took all morning (his ward rounds were in the morning). It was initially frustrating. But soon junior doctors realised that there were not many 'to do lists' not many things to actually pending. We were not running like headless chicken after the ward round. We ended up having more time for the doctors mess, more time for learning, more time for everything else.

Any really abnormal results were acted upon at the earliest as anyone would. The next time the house surgeon had any serious work was at 3.30 pm to check on any changes to patient's status which were not already informed and to check on investigation results that were not direly abnormal and to act on it. Barring a late finish in theatres Mr Desai would always visit the wards and speak to the senior nurse at 5 pm every day and conducted the equivalent of a board round. Any patients that needed to come to the attention of the on-call teams were noted - Mr Desai would speak to the on-call consultant and Mr Desai's registrar would speak to the on-call registrar. 5.30 pm we were gone.

I do not know the precise results of Mr Desai's work. All I know was that everyone including me was of the impression that his work was good. It was organised, it was thorough and all elective work was directly consultant delivered or delivered in the presence of a consultant. An aside which could be a nugget as a mark of the quality of his work: all his patients who were having elective major surgery were seen by the physiotherapist with a special emphasis on chest physio - blowing balloons et al - it was no wonder we thought his patients did well.

I did not know about lean concepts in 1994. When I later became aware of lean I realised that this is a single piece flow ward round if there was ever such a thing described.

I recommend it.

© HEMADRI

 
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PS: I have heard a number of patients credit Mr Desai with commencing gastrointestinal endoscopy, vascular surgery, endo-urology and triple assessment breast clinic service at Scunthorpe; I am sure he played a major part in these. I know of a few patients who still remember him and praise him.

Generalists

GENERALISTS FOR UK HEALTHCARE - WILL IT WORK?

A rethink of training is happening. We debate that here.

In the USA most doctors undergo four or five years training depending on whether they are medical or surgical fields and become 'generalists' (family practitioner, internal medicine physician or general surgeon). They provide the bulk of care in their areas. Some of course choose to sub-specialise into ever narrowing areas for which they undergo a further 2 to 3 years of 'fellowship' training. When it comes to care delivery the patients do have a choice (at least in theory) of seeing their Family Practioner, 'generalist' or sub-specialist; the family practitioner and/or the Emergency Department has the choice of referring patients to generalist or sub-specialist as the situation demands. Of course the generalists refer on to the specialists as needed.

Moving from the mature economy USA example to the advancing economy of India the situation is more or less the same. Doctors after their MBBS are allowed to practice as GPs and recently there is a trend of emerging opportunities to train further to become an advanced family practitioner. Many doctors obtain post-graduate training and become 'generalists' general physician, general surgeon, etc. Some obtain sub-specialty (though the Indians love the term 'super-speciality', they never call their narrow field as a 'sub-specialty') and become cardiologists, vascular surgeons, et al.

In the UK there has been in the guise of rather misguided and seemingly always wrong work force planning, the training system has, since Calman, delivered 'sub-specialists' to deliver care in the NHS. There are no more 'general physician' or 'general surgeon'. In theory a collaborative approach of all these good people is supposed to deliver high quality integrated care to the patient at the front line. In practice it falls and fails often and more. 

At the real front end where direct care is delivered by the trainees and sub-specialty doctors the sub-specialist attitude becomes a big problem. In these young doctors' minds they are very keen to learn their sub-specialty skills and they are not interested or do not have have the time to learn or deliver 'general care'. What it translates into are junior doctors who are unable or unwilling to do 'general' care. I have heard from many about numerous instances of junior doctors and non-consultant doctors being unable to do things like supra-pubic catheterisation, torsion testis, embolectomy, etc despite being on call for their relevant generality in DGHs (or even teaching hospitals). The 'sub-specialist' has to be called out to deliver what is essentially general care.

There are strong arguments for the UK sub-specialist model, mostly emotional. An example such as 'would you like to obtain the best care from the most highly trained person or be messed up by a generalist?' However since we do not train generalists in the UK we do not know what kind of care a generalist might deliver; since there are other countries training generalists, we know that generalists do deliver a high standard of care. What we also know is that care can slip between sub-specialists, care can slip due to non availability 24/7 of sub-specialists in every hospital, care can slip due to difficulty of access to sub-specialists (in the version of centralised care in major hubs) and sub-specialist based care is costly. 

Of course my favourite argument is costly care is generally not beneficial at a system level.

The UK is now at the closing stages of the 'Shape of Training' consultation to explore potential future models of training that would suit UK requirements. No favoured models have been decided yet, no decisions have been made. The consultation includes a model where more generalists would be trained to deliver the bulk of care across locations. Even within this model, UK would obviously still train sub-specialists but their numbers and the location of work could be limited.

There are many reasons why the idea of generalists would not work. First and foremost is the culture in UK where the current sub-specialist model is seen as inherently superior and in those circumstances change becomes frustratingly difficult. Sub-specialists seem to carry more glamour, power, earning opportunities and even respect; hence it is a natural aspiration for most doctors; even many general practitioners in UK want to be 'GPwSI'. Broad knowledge seems not be valued as much as deep knowledge (and by the way, broad does not equate to superficial).

However, it is important to question whether in a small country (at least relatively in terms of population and geography) with current economic difficulties it is possible or reasonable to train and maintain sub-specialists 24/7/365 in every location that care is provided; which we will have to do if we have to deliver high quality of healthcare to our population. With care being delivered outside conventional settings closer to the patient and community with concepts such as tele-health, virtual consults, hospital at home, becoming real; with technology enabling remote diagnosis to be made (smart phone ECGs and blood tests at super-store car parks); with Dr Google and crowd sourcing having the potential to be more accurate/knowledgeable than individual specialists we do need to think if the training of doctors in UK needs to move to a 'generalist' model.

I am in support of training generalists who would have in the hierarchy of NHS appointments have a higher or equal level as specialists. They should be charged with the specifics of designing and delivering high quality of care (including management responsibilities). A generalist would be far more likely to interact closely with the patients, general practitioners and specialists than now - that would be a boon and a refreshing change to the passing-the-parcel that is currently played with patients due to a system that is divided into very narrow specialties. There will of course be the rare generalist who is blind to her/his limitations who can be very dealt with proper systems in place.

What do you think will work for UK/NHS? Are generalists a good idea?

©M HEMADRI 

Follow me on twitter @HemadriTweets

Info:

Shape of Training: http://www.shapeoftraining.co.uk/

I provided oral evidence to the Shape of Training consultation as a part of BAPIO team and hence we had a specific remit to support the interests of IMG and BME doctors apart from providing general views on the various proposals and our own views as individuals. This blog does not discuss contents of BAPIO's evidence to the consultation; the above are my personal views.

Likeability and Interviews

Guest Blog from SAMI (Success At Medical Interactions)

One of the main factors in being successful in an interview is likeability.

Some may say that is unfair, some might be surprised. Let us explore this.

Once you are shortlisted and invited for an interview it means you have met the essential criteria which means you are appointable. On that basis you have an equal chance of actually getting the job as anyone else. If you are invited for an interview it may also mean that you have met many of the 'desirable' criteria. The chances are that the content of any answers you may give is also going to be more or less the same as the other candidates at an inteview, i.e. the knowledge is likely to be equal amongst the shortlisted candidates.

Well, if you have the essential criteria and your knowledge level is also the same then how can an interviewer make a decision?

The decision is therefore likely to be based on whether the interviewer likes you.

Jobs for the boys, known candidates, mentors on interview panels, old school ties, social networks and many other link-ups all mean just one thing in an interview context. It means that the interviewer likes the interviewee.

Likeability is very important. It will be pretty difficult, if not just impossible to work with someone that you do not like. We at SAMI, argue that the likeablility should be based on contextual performance based 'professional likeability' rather than personal links history based 'social likeability' (which is important and relevant in general/social life). This means that the interviewer makes a decision on whether the candidate is likeable purely on the interview performance of the day rather than any prior knowledge of the candidates that the interviewer might be aware of.

That will be the basis of Success of people in healthcare.

That is part of what we try to train you in when you attend the SAMI interview courses - on how to be likeable within an interview context thus potentially outshining anyone who may have social or personal links with the interview panel. Its not easy, there are no guarantees but no harm in trying!

Reposted from SAMI blog

http://successatmedicalinteractions.blogspot.co.uk/2012/05/likeability-and-interviews.html

NHS Staff Survey - do we know what we are talking about?

The 2009 NHS staff survey is now out. The Academy of Medical Royal Colleges did some more analysis of the findings. Having looked at it, my reading of it shows that (Note that though I am using consultant response figures here, broadly similar inferences can be made from all other staff responses as well):

a) Though 50% of consultants agreed that they understand their role and where it fits in' 100% of consultants felt their role made a difference. That says a lot about clinical engagement and culture in the NHS. You don't know what your role is but you assign yourself such a high value that you know it makes a difference. If you did not know what your role was how can you made a difference! And wonder how they knew that they made a difference when only 27% felt they had a well structured appraisal (is the appraisal not trusted?).

b) 74% of consultants but only 50% of trainees felt that can contribute towards improvement.

There are many other interesting inferences that can be made and I am happy to share the analysis if you wanted.

What is very important for successful healthcare is for the people to be very self aware (soft skills) and have the knowledge on how to make improvements (technical skills of improvement). Healthcare is full of absolutely brilliant people with high qualifications and often very scientific minds who think that either they have the people and improvement skills already or such skills are not very relevant to day-to-day clinical practice. That gap needs to be addressed. It is possible to do so.

Find out how your place is doing http://www.cqc.org.uk