Published: 08/05/2003, Volume II3, No. 5854 Page 20, 21 23
As chair of the body that harnesses the combined power of the royal colleges, Professor Peter Hutton wields considerable clout in medical politics.But his stance is very different from that of the British Medical Association, and he believes that it is not too late to engage clinicians in the process of reform
' hese are just my personal views, ' is something of a refrain in conversation with Professor Peter Hutton. The outgoing president of the Royal College of Anaesthetists and current chair of the Academy of Medical Royal Colleges is treading carefully.
Little wonder, since his views are far removed from the government-bashing and managementderiding opinions popular in medical politics. This is not to say that Professor Hutton is a Richmond House patsy. The government, he says, 'has got itself into a mess' over the European working-time directive and consultant contract.
But he is willing, as chair of the body that harnesses the combined power of the royal medical colleges, to consider how the nature of the medical profession contributes to the problems facing the NHS and how these might be tackled.
This has secured him a powerful position within policy circles.
Consider these two passages from his recently released 'president's statement', dealing with the issue of doctors' responsibility and pay:
A small but increasing number [of trainee doctors] keep strictly to their minimum hours. [Some] take no responsibility for the integrity of the service.
One such person impressed on me the importance of work-life balance and quoted the words of Thomas Jefferson that: 'men are endowed with certain unalienable rights, among these are life, liberty and the pursuit of happiness'...When he wrote those words, I am sure that Jefferson was thinking about slavery, not the number of nights on-call.
And: Another myth of medicine is that we are underpaid for what we do. In fact, there is no other group who has such job security at the salary we obtain or who are allowed the freedom we are to pursue other work.
But Professor Hutton's real cause célèbre is the role of the consultant and how possible changes could benefit both the service and the profession.
He quickly sketches out how, for example, the increasing accuracy of diagnosis and greater agreement on the 'optimal treatment of common conditions' such as asthma, diabetes, hypertension raises questions about which consultations must be done by a qualified doctor and which could be done by other professionals, working to a protocol.
Creating a new skill-mix is essential because, even with the planned increases in doctor numbers, 'all the projections I have seen suggest demand will completely outstrip the ability of [health] services to be delivered by a medically qualified person - as we define medically qualified now, ie somebody on the medical register.'
This is a crucial point. Other countries, says Professor Hutton, do not create this problem for themselves.While undergraduate training is similar, postgraduate training is shorter and therefore trainees make up much less of the medical workforce.
'In the UK, virtually no hospital could function without trainees.
In Europe and the US, the proportion of hospitals using trainees is less than 20 per cent.'
Other countries also 'train people to different levels of competency' and achieve a 'much wider skill distribution throughout the medical team'. Because of this, '24hour care is delivered by people who have completed training - to some level or other'.
The desirability and implications of offering out-of-hours care by 'trained staff ' is one that Professor Hutton believes could have a profound effect on UK healthcare. In his presidential statement he paints an intriguing picture:
It is worth speculating that if there were sufficient public pressure (and it might be demanded in contracts with primary care trusts), under what conditions consultants might be prepared to do night call in hospitals and what effect it would have on the service.
All unnecessary operations would cease, working at diagnostic and treatment centres would become instantly popular, there would be enormous pressure to reduce the number of acute sites and, to ease rotas, the acceptable definition of when somebody was 'fully trained' would change.
Professor Hutton wants a 'public debate' about the UK's medically managed model of care. In this, he says, 'we would have to be realistic and honest with the public about what constituted a trained doctor', were the UK to move towards the overseas model.
He is in no doubt that 'consultants should be leading teams, but accepting that not every item of care will be done by them.'
Taking a team-based approach means reviewing both medical recruitment practice and career paths. No bad thing, according to Professor Hutton.
'When I was at medical school, the unwritten rule was that the only two, finally respectable positions were being a consultant or a principal in general practice, ' he says. Everybody else was seen not to have achieved. That is completely inappropriate, because it encompasses many excellent people doing excellent work.'
A team approach would avoid this win or bust attitude - with its automatic creation of dissatisfaction among those who do not make the grade. It would also make the traditional practice of 'recruiting people during their late teenage years on the basis of science A-levels' even more inappropriate than it is at present.
'The more open courses taking in people from a variety of backgrounds will make a huge difference, ' says Professor Hutton.
'Recruiting people at a later age produces a better balance of personality types and personal objectives.'
So much for the future of the profession.What about the present and the current apparent stand-off between hospital doctors and the government? Professor Hutton is keen to put a historical and philosophical slant on the situation.
During the 1990s there were 'real sequential cuts in money for patient care', he says. There was also a series of 'trivial, but symbolical' moves such as the ending of free car parking for consultants.
Then came the introduction of targets and the European workingtime directive, which middle-aged consultants feared would force them to return to the nightmarish working hours of their youth.
Factor in the desire for a less work-centric lifestyle among younger consultants and the government, in Professor Hutton's words, already faced 'a difficult psychological component' in its dealing with doctors.
This has been compounded by the 'probably unintended' consequences of government policy, which set 'ambitions for the service that are not achievable in the short term' and a rash of doctor-bashing.
Put everything together and you have a profession eager to protect itself from 'unfair' allegations or expectations.
The result has been that the government's - welcome - 'huge investment' has been greeted with the belief that much of it will not be used to the service's 'best advantage'.
Many ennui-afflicted consultants 'have removed themselves from the decision-making process by becoming passive'.
Professor Hutton says there is no doubt that some doctors have not been given the opportunity to contribute to service change. But he is clear that consultants have a wider duty and should not simply concern themselves with the patient in front of them, or at the top of their lists.
'If you are an NHS consultant, you are indirectly employed by the British public and you should regard yourself as a senior corporate employee, part of whose role should be to take part in determining the objectives of the institution in which you work, ' he says.
'Consultants in all specialist areas need to develop a greater awareness of community needs.'
Professor Hutton continues: 'I am sympathetic to a certain extent to the view that the medical profession could have taken a stronger, more innovative lead [on reform].
It has not been deliberate, but the pace of change and current structure of hospital care hasn't led to a great deal of joined-up thinking between consultants and other clinicians - and that inhibits mutually agreed solutions.'
However, he believes 'the only chance the government has of delivering its agenda is to get existing doctors to deliver more items of care and to stop people retiring early'.This 'requires a better relationship between medical profession and the government', which would persuade doctors 'to talk constructively about volume throughput figures'.
Problems in this area are made worse by waiting-list targets, he says, adding that 'the area that needs to be most improved is the area in which there is maximum friction'.
'No doctor is kicking against the target for clot-busting drugs and a whole range of other targets.'
But Professor Hutton believes progress is possible and sees the royal colleges playing a major role in helping to re-engage the medical profession.
Beneath the sound and fury of the consultant contract row, Professor Hutton says the government and royal colleges having been working together well.
He cites two significant advances.
The first is academy guidance on implementing the workingtime directive. This includes the Department of Health's agreement that any changes must not compromise patient safety or care, while also encouraging colleges to co-operate with the DoH and trusts in exploring solutions provided by skill-mix and service reconfiguration.
The second is the joint memorandum of understanding between the academy and the DoH.This commits them to work together 'to improve the availability of high-quality patient care'.
Specifically, the colleges secured their sought-after places on the new postgraduate medical education board and the DoH won a more helpful approach to the way colleges monitor training.
Early one morning, a couple of days after his interview, I receive a call from Professor Hutton.About to fly out of the UK, he wants to clarify a few points before heading for check-in.
The first is to complain that 'the profession, royal colleges and government are doing absolutely nothing' to tackle the implications of moving to a medical workforce with fewer trainees.
He stresses the need to establish a 'slight shift in [medical] job descriptions' as 'qualified' staff undertake a greater proportion of the workload. He also wants to stress how the royal college charters mean that, with the exception of their role in medical education and training, they are focused on serving the public: 'This separates them from specialist bodies like the British Medical Association', he reminds me.
Expect Professor Hutton's 'personal views' to continue to provide an influential alternative voice to the one emanating from the doctors' union for some time to come. l
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