John Black is a living legend

The President of the Royal College of Surgeons has had his say on the EWTD and its disastrous effect on training today, and he certainly doesn't mince his words:

"The Junior Doctors Committee of the British Medical Association met for its annual conference on May 9th. A motion which was passed by a large majority included the statements “The current provision of service and training in the 9 surgical specialties mentioned above will not allow optimal training to be achieved in a 48 hour week” and “The changes required to optimise training will not be implemented at Trust level by the August 2009 deadline”. Good news one might think for those opposed to the introduction of the 48-hour week for surgeons. At last the BMA juniors have woken up to the fact that the EWTD is a disaster for training. However in the latest BMA News Review their spokesman ignores the motion passed by his own JDC and confirms that official BMA policy remains that the 48-hour week should be introduced in August. Their own JDC admit it is impossible to train surgeons in a 48-hour week but still want to see it brought it. This can only mean they do not want surgeons to be trained under the current system, an interesting and challenging position, which I hope to see clarified.

On 20th May Alan Johnson the Secretary of State for Health wrote to the Chairman of Medical Education England (MEE) saying “I would like the MEE to commission the Postgraduate Medical Education and Training Board (PMETB) to conduct a review of the quality of postgraduate medical training within a EWTD compliant working environment”. He also states that “There is no evidence that training is any less effective since the gradual reduction in junior doctors’ hours over the past ten years, or that greater numbers of trainees are failing their annual assessments where 48 hour working has been introduced”. Surgeons will be astonished by the Secretary of State’s complacent belief that training is no less effective than before at a time when surgical trainee logbooks are the thinnest in living memory. However aside from the minister giving orders to the independent MEE and to the independent regulator PMETB, this initiative is very welcome. The Board of MEE had already decided to look at the effects of EWTD on training at its next meeting on June 8th, and it is to be hoped that PMETB will not distance itself from the current training crisis, an approach it adopted during the MMC/MTAS crisis of two years ago. Mr Johnson also joins the BMA in his self-contradictory approach. Everything’s fine with training, but I want you to conduct a review. Why? Because we all know it isn’t! Again we await clarification.

As August 1st approaches the Department of Health is collecting data from Strategic Health Authorities (SHA) on progress towards EWTD compliance. The College has looked at the data for the surgical specialties, and I am grateful to the Regional Specialty Advisers and others who helped in this task. On May 21st I attended a meeting of the Department of Health EWTD team and the Academy of Royal Colleges to discuss this emerging data. It was a truly frightening occasion, as specialty after specialty described the reality of mythical rotas with gaps which cannot be filled, dangerously thin levels of cover, multiple handovers and unplanned and untested service re-configurations. The number of unfilled junior posts, both service and training, now approaches 3,000. The April SHA data do not show further movement towards compliance compared with March. Overall national compliance fell from 78 to 72% as paper rotas are revealed as mythical. As the situation is examined more critically, I just wonder what the true figure will be, 60%, 50%, or even less?

I attended the recent Association of Surgeons meeting in Glasgow and was heartened by the massive support for the College position. However a speaker from the floor made the point that it is quite likely that the 48-hour week will be forced in whatever we do or say and that consultants will as ever shoulder the burden for the sake of their patients. He has a point but you must not despair. The fact is that the NHS will not be 48-hour compliant in August. The emerging SHA data prove this. The EWTD is unworkable, dangerous for patients and disastrous for training. This battle is for the soul of surgery, and must and will be won. Patients will ultimately suffer and some may even die if it is not. I do not know when, but sooner or later this government or its successor will have to exempt surgery, and I suspect many other specialties too.

John Black
President"

Absolutely awesome. The BMA have had their head in the sand, the DoH and the politicians are in denial, the effects on training are disastrous, while the consequences for patients could be catastrophic. John Black is spot on, the man is a legend, however he may well have kissed goodbye to his peerage.

EWTD and the great deckchair rearrangement

The following description of the shocking state of affairs concerning the European Working Time Directive (EWTD) and the NHS has been largely stolen from a great piece on Doctors.net.uk, given the enormity of the problem I just felt this needed airing to as wide an audience as possible.

After a huge amount of pressure, and only 12 weeks before the full weight of the Working Time Directive hits the NHS Alan Johnson has ordered an enquiry into the effect of EWTD on the training of doctors in the UK.

In announcing it Alan Johnson has tasked MEE (Medical Education for England) to commission PMETB to consult 'stakeholders' as to solution to the imminent changes. This ultra-arms-length approach hints at lack of foresight and planning - arguably not boding well for a quick-fire solution in the 12 weeks that remain.

The writing has been on the wall for some time, and those pushing the WTD agenda cannot fail to have heard the message. In a recent joint statement the Royal Colleges of Anaesthetists and Surgeons wrote "Both colleges believe that the implementation of the WTD is in serious danger of having a deleterious effect on medical training, patient safety and service delivery."
A pilot study from Galway last year found that "all [the SHOs'] reported a deterioration in training and 81% felt that patient care suffered".

A Royal College of Physicians study found that "...the new 48-h working week has resulted in significant reductions of not only the quality of patient care, but also of general medical and medical specialty training. In particular, continuity of patient care has been affected adversely." Two former Royal College Presidents wrote to The Times this week and argued that "It is evident from many sources that quality of care of patients and proper teaching and experience for doctors in training cannot be provided for adequately in many specialties within a 48-hour week. This is particularly true of acute medicine and surgery".

Yet the Chairman of MEE, Sir Christopher Edwards, claimed today that the Secretary of Health was being 'proactive' in ordering this enquiry. Bearing in mind the timescale behind the implementation we think this is a new meaning of the word 'proactive'.

Last week the Department of Health admitted up to 28% of rotas were not going to be able to comply with the WTD by August. Some of those which were ostensibly had plans were completely unrealistic and were dependant on recruiting large numbers of doctors over the next few weeks. In a presentation made last week by Wendy Reid, the National Clinical Advisor to the EWTD, she acknowledged "Its not wise to go for a ‘big bang’ approach on August 1st". She also highlighted that despite throwing over £150million at the problem there were still many unanswered questions.

Implementation of the WTD requires more than just a reshuffling of rotas. It requires a major rethink in the way clinical care is delivered in hospitals, with changes to staffing levels and work patterns. Such a 'whole systems' approach requires far-sighted planning, central coordination and clear leadership. The government have had years to look at this. Why have they only noticed the impact on training now? The words from the new chair of MEE also make this man appear either completely out of touch with reality or so far up the government's derriere that his job is pointless.

MMC, sub-consultants and the Trojan Horse

"Remedy have obtained documents through a Freedom of Information (FOI) disclosure revealing previously undisclosed motives behind the MMC reforms of 2007. In short it appears that MMC was something of a foil by the powers that be to usher in the Subconsultant grade and change irrevocably the career prospects of all UK trainees......"

Excellent ferreting Remedy. I would strongly advise anyone interested in medical politics to read through the documents that the DoH have finally been forced to release.

In my opinion the rank dishonesty shown by the DoH throughout this whole sorry affair reveals why the health service will never flourish with these bullies at the helm. If only those in the positions of power were willing to cooperate and work with people in order to improve the systems that are in place, if only. The current regime would prefer to cynically spin the facts, deliberately hide their real motives and smuggle their corrupt reform agenda in via the back door. Shame on them.

GMC in denial

The story of the German GP who negligently killed an English patient whilst working as an out of hours GP locum has been in the news a lot recently, and quite rightly so. It appears that this was not an isolated incident either, this GP was clearly way out of his depth and other patients died that day.

I do not wish to dwell on this case because it is the theme that is important, the theme being the fact that non-UK trained doctors from the EU can easily register with the GMC after only the most minimal of checks, they are then free to compete with our own doctors for jobs, despite the fact that their education and training may not be nearly comprehensive enough to prepare them for the work they will be doing in the NHS. We now know that these EU trained doctors can then kill patients negligently, return home, receive the lightest of punishments and then return to practice as if nothing has happened. This is a disgrace.

If there is going to be a free market of labour in the EU in terms of health care work, then there must be a rigorous system of regulation in place that holds people to account if they make negligent errors whilst working away from their homeland. The blame lies squarely at the door of the government who have signed us up for this free market of labour without thinking of the serious consequences of a dangerously patchy system of regulation. Any doctor working in the NHS will tell you how they have encountered several non-UK trained doctors from the EU who have shockingly bad language skills and who lack even the most basic of medical knowledge, yet strangely they had no trouble getting their full registration from the GMC. This is not good enough.

There are many medical schools in certain EU countries that do not train doctors to the level of competence that our own UK graduates achieve, however the GMC cares not for the standard of your medical degree, any EU degree is good enough for them, while their language test is so easy that even a martian could secure top marks. Bizarrely excellent Australian and New Zealand graduates are now faced with a mountain of stupid paperwork before they can practice in the UK, while some of their dangerous counterparts from the backwaters of the EU can get in without any trouble at all. Well done the government and well done the GMC. Although the free labour market helps you push people around, it is killing patients at the same time, well done.

Watch this space: MMC

"Modernising Medical Careers (MMC) is a programme of radical change that aims to drive up the quality of care for patients through reform and improvement in postgraduate medical education and training. "

The government's stated aims of MMC are directly quoted above. The government also claimed that all it was doing was fair and transparent:

"One of the intended benefits of Modernising Medical Careers (MMC) was to ensure a transparent and efficient career path for doctors."

There was also meant to be better training for doctors and 'evidence' behind this improved training system:

"For patients, it was intended to mean that a higher proportion of care would be delivered by an appropriately skilled workforce. For trainees, the new programmes’ structures meant an assured high quality of training, better formal supervision and continuous development of acquired competencies, backed up by good evidence."

It is strange that despite such noble motives, the reality is virtually the polar opposite of the government's hollow chatter. The training quality is not better, the competency based ladder is simply a way of dumbing down health care so that less training and skills are needed for its delivery, this is beautifully demonstrated by Dr C's Pharmacist's tale. The quality of care is consequently not better, it is worse, as less experience and skill are needed to treat patients these days. The 'fair' MMC process is excellently demonstrated by this sad tale from a junior doctor who has actually experienced the reality of this grossly unfair and shoddy system.

So training is worse, there are less hours for training and a much smaller window of opportunity for learning one's trade, and at the same time training is being shortened. Something does not add up, these promises of better care seem a blatant lie. So what are the real motives for MMC, I would advise you to watch this space for some rather important breaking news.