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View from the front-line
Ed Fitzgerald discusses the future of medical training and the effects of the European Working Time Directive
very generation in medicine faces challenges during their professional careers. As a medical student, the realities of NHS employment can be a shock to the system after many years of studying. Twenty years ago, junior doctors were working 100-hour weeks as routine, with hourly pay below that of the hospital cleaners. In 1991, the introduction of the “New Deal” for juniors oversaw massive changes in our terms and conditions of service . In the decades since then, the situation seems to have slowly deteriorated, and now, more than ever, medical students need to be prepared for the realities of being part of the modern medical workforce. You never know what unforeseen changes lurk around the corner and for those who survived the House Officer and early SHO years intact, MMC and MTAS came along in 2007 to ‘fix’ an area that many would have argued wasn’t broken. Thankfully, the well-publicised collapse and raking over of these ashes has led to a clearer, if more competitive, pathway into specialist training. However, the NHS landscape is constantly changing and a little crystal ball gazing is required to predict the next major hurdles.
have flexed the rules (some might say completely ignored them), our British tendency for ‘gold-plating’ them is likely to cause some rota problems in the not-too-distant future. Why is this important for juniors? Changing work patterns have already led to the loss of free accommodation for Foundation Year 1 House Officers, as the EWTD indirectly removed the requirement for being ‘resident’ on the hospital site.
compliant rotas successfully) find medical staff deployed on a full-shift rota. Ever-changing working hours, little continuity of care, and a lack of an identifiable team, both to work with and also to deliver patient care, leads to unhappy doctors— that’s before we even touch on the delivery of training. Some medical staff will undoubtedly be pleased with the promise of a further reduction in working hours, but many will lament the decreased pay-banding that comes with reduced on-call work. Many more will rue the reduction in training opportunities that this brings. One argument is that this time was always a myth; that time spent delivering service could never equate to time spent training. Whilst an element of this may be true, there is no doubt that some areas of the medical profession will be affected by reduced working hours more than others. So-called ‘craft’ specialities, including surgery, will be hit particularly hard. Those that disregard their working hours, to stay and assist with a patient or procedure in the name of training, will place themselves in very murky water with respect to medical indemnity, should an error then occur. Given the streamlining of training brought about by MMC, this double-whammy is leading many to conclude that the consultant of tomorrow will be a very poorly trained relative of what we have today.
Workforce issues remain high on the medico-political agenda. In August 2009, it is likely that many of these will come to a head, when the next stages of the European Working Time Directive (EWTD) are introduced. Whilst many European countries
14 Autumn 2008
IIlustration: Tom Bannister
Whilst most NHS Trusts have quickly leapt on this as a way of saving cash, most have not yet started planning the rota changes necessary for working-time compliance that the EWTD also demands. Those that have tried (some have even introduced
the next stage of the EWTD, and the To many, the simple solution is to imminent bulge of CCT-holders extend specialist training by pushing who don’t have consultant jobs to back the award of the Completion of step into, and the future looks a little Certificate of Training (CCT) at the hazy. Worryingly, I have yet to speak end of the ST/SpR years. For various to a current consultant who does reasons, there seems to be a lack of not think that this ‘sub-consultant’ acceptance amongst professional grade is inevitable. Who can blame bodies that this is required. At the their apathy, given that the current same time, post-CCT, further spe- situation offers the opportunity for cialist training in surgery is being old-style Senior Registrars to be arranged by the Royal College of appointed, hence lightening the Surgeons of England, in the consultants’ load? shape of Post-CCT “The consultant of tomorrow Fellowships. The incongruity The issues here are comwill be a of these two positions plex ones, in need of worries many. poorly-trained open debate. Faced with relative of what unemployment given Are we seeing specialist the lack of consultant training coming in a full we have today.” posts, what trainee circle with the covert re-introduction wouldn’t want to take a post-CCT, of Senior Registrars? Or are we seeing non-consultant job? Nevertheless, to a more worrying spectre: the rise of potentially sell them as training posts a post-CCT sub-consultant grade? is disingenuous, when the purpose of Certainly there seems to be a body of the CCT is to indicate that the holder evidence to suggest the latter is is fully trained to consultant level. desirable for many NHS Trusts. Consultants have priced themselves Future uncertainty out of the market with their new The final stage of the EWTD may contract, and the prospect of be a catalyst in bringing about a employing a consultant-level, fully- raft of changes in our future career qualified ‘worker-bee’ on their own structures. Post-CCT training posts terms and conditions must be very are already being advertised by some appealing to many cash-strapped hospitals, but the issues raised by these go far beyond the creation of a Trusts. new tier of service. If we employ Add to the mix the need for extra larger numbers of junior, consultantpeople to cover rota gaps created by level, CCT-holders then who will
Time for a sub-consultant?
supervise them? Are we moving towards the European ‘chef de service’ model, where a senior head of department takes control of their more junior consultant body? What then will happen to consultants when NHS Trusts realise that employing more juniors, post-CCT, on their own custom-made contracts may be significantly more cost-effective? Throughout all of this, how will patients view these changes? The future is uncertain and the medical profession needs to engage and help shape its own future rather than passively reacting to events. This is not something many medics are necessarily comfortable doing, although the MMC events of 2007 have done much to awaken our interest. Most of all, current medical students need to be aware that the NHS they will find employing them in a few years time may be a very different animal to the one they see now.
Edward Fitzgerald is a specialty trainee in General Surgery, working at Nottingham University Hospitals NHS Trust. He was Editor of the Oxford Medical Gazette 2002-2003 and is currently Vice-President of the Association of Surgeons in Training (http://www.asit.org/). Reference  Department of Health, Social Services and Public Safety. New Deal for Junior Doctors. (February 2006). [Online]. Available from: http://www.dhsspsni.gov.uk/scujuniordoc-2 [Accessed: 09 July 2008]
Q: Does modern medical education dull the minds of medical
students and prevent them asking questions?
A: “ ‘Medical students here are so bright that they don’t need teaching. Be careful that you don’t get in their way’”. This is what I was told by the director of clinical studies many years ago. Are you really that bright? Well, yes actually you are. I have travelled the world looking at medical schools and students and you are sans pareil. There are harder working students for sure, but as Jeremy Clarkson would say, when you are on song, there is nothing which can catch you. All we teachers have to do is find the throttle pedal and floor it!”
Christopher Bulstrode is a consultant orthopaedic surgeon and SHO in A&E at the John Radcliffe Hospital, Oxford, and Professor of Medical Education at the University of Oxford
Oxford Medical School Gazette