72
Correspondence
eliminated but may have been temporarily stemmed by the introduction of the EM1 scan), and coronary artery surgery has recently added another burden to the already heavy load in cardiothoracic units. Transplant surgery, the increasing demand for anaesthetic staff for obstetric units and pain relief by epidural injections constitute yet other groups of cases where additional anaesthetic help is required. The amount of work which can be done in Pain Clinics is an area where the demands on anaesthetists are substantially insatiable. In Intensive Care Units anaesthetists do not only deal with critically ill patients and administer the units. In some parts of the country they have become theclinicians who carry the main burden of looking after cases of poisoning and head injuries, as latter are now all too often admitted to Intensive Care Units in hospitals where there is no neurosurgical service. It is therefore not surprising that there is a shortage of anaesthetists to meet these so rapidly expanding demands. The North West Regional Health Authority provides an example of the shortage. It has under consideration sixteen unsatisfied applications from Area Health Authorities for additional consultant anaesthetists. In the year 1976/77 one additional consultant anaesthetist appointment was authorised by the Department of Health and Social Security (DHSS) and in 1977/78 one further appointment was authorised. Even existing anaesthetic establishments are not being fully filled; for example Trent Region recently had thirteen consultant vacancies which have been advertised and for which there have been no suitable applicants. The DHSS, from the statistics supplied to them by the Areas reckon that there are 41 vacant consultant posts in England and Wales. A further 82 are filled by locums but many of these are only a few sessions and are inherently unattractive. Perhaps the best measure of the shortage is the fact that 30 consultant posts failed to attract a suitably qualified applicantin the last year for which statistics are available. The number of senior registrars in training in England and Wales is approximately 280. Therefore, if the senior registrars spend three years each in the
grade, some 90 should be available for consultant appointments in each year. In fact, according to the calculations of the DHSS, in the year ending April 1978 there were only 60 senior registrars available to take up consultant appointments. In order words, thirty senior registrars had been lost to the Health Service from that particular year’s generation. It is possible to go further back into the situation. Recruitment to the senior registrar grade depends on the obtaining of the FFARCS qualification. Nearly 200 pass the final examination for the FFARCS in England alone each year, and there are an appreciable number who successfully sit the FFARCS of the Royal College of Surgeons in Ireland. In short, there are some 200 potential senior registrar applicants in England during each year, including some Scots, and of these no more than about 100 become senior registrars, and not infrequently there is only one applicant for a less attractive post. The remainder, with the exception of some 20 who become Senior Registrars either in Scotland or Northern Ireland, are lost to the service. Why there should be this tremendous wastage is by no means clear. It is certainly possible that some of those who sit the final FFARCS are married women who elect to start a family on passing the examination. A small proportion of those who pass the examination come from abroad, specifically to complete their training in the United Kingdom, and return whence they came. Others no doubt decide that consultant practice is not attractive and opt for general practice, and yet others emigrate. But, even taking into account those possible causes of loss, the fact that something like 50% of those who pass the FFARCS examination, and are therefore eligible for senior registrarships in the United Kingdom, actually choose to apply for these, must cause grave concern, and might well be a profitable matter for further investigation. Department of Anaesthetics, The Royal Infirmary, Manchester M I 3 9 WL
A.R. HUNTER
A College of Anaesthetists? May I, through the courtesy of your columns, comment on the September 1978 Newsletter from the Dean of the Faculty of Anaesthetists, Royal College of Surgeons? While Newsletters are not, perhaps, intended to provoke replies, that written by the Dean sets out his personal views on the Faculty/ Independent College controversy and I, as an ordinary Member of the Board, would like the opportunity to express my own. May I first draw attention to the following
sentence in the Newsletter: ‘Whatever changes are to take place in the future, whether these occur within the College or outside it, let it clearly be understood by all Fellows and Members, that those changes can only be initiated from within the Faculty and in consultation with the Faculty’s present partners in the College.’ There is no doubt in my mind that change is still needed and that, eventually, that change will require the creation of an independent College of
Correspondence Anaesthetists. There is equally no doubt in my mind that that change, when it comes, must stem from a majority within the Board of Faculty. Thus, I find myself in total agreement with the Dean when he says, ‘If the Board of Faculty decides that the objects for which the faculty exists would be better promoted in a separate ccllege, then its responsibility is to inform the Fellows of that view and to tell them how it can be achieved’, indeed, the only improvement I could make to that sentence is to change the initial ‘If’ to ‘When’! May I now comment on some other aspects of the Dean’s Newsletter? I cannot share the Dean’s depression and disappointment at the way in which the debate about a future independent college of anaesthetists has been conducted; to me, it is a sign of a very healthy speciality that it should concern itself with those organisations that govern its future. It is true that much of the debate has been promoted by the Association of Anaesthetists but the Faculty has not only been perfectly free to take part but positively invited to do so on more than one occasion. Indeed, I welcome the current Newsletter both for its reasoned and moderate tone and its attempt to set out the benefits of staying within the Royal College of Surgeons. Many of these benefits are very real and I would certainly not wish to deny them. Others, however, are questionable. ‘We are currently part of an active and powerful College: to be independent and weak is not necessarily preferable to being strong in a state of mutual independence.’ This is a very forceful argument but who has ever advocated the creation of an independent and weak college? We are the largest single speciality in the country. What is to stop a College of Anaesthetists being independent and strong? ‘The evolution of the academic organisation of anaesthesia in isolation from surgery is as unthinkable as the evolution of surgery in isolation from anaesthesia.’ Why, one asks, does the creation of an independent college of anaesthetists isolate us from surgery? Is it so difficult for sister colleges to work together? Might not our relationships with the College of Obstetricians and Gynaecologists and the College of Physicians be improved if we were all on an equal footing? The Dean notes that the Faculty is now independent within the College Constitution. Functionally, I have no doubt that this is true although purists might argue that, without financial independence, there can be no true independence. The claim that politicians can easily ignore a succession of independent and conflicting claims is very true. But is independence a reason for conflict, and, in any case,
73
the Conference of Royal Colleges and Faculties has succeeded in giving a corporate voice to all collegiate institutions. The resources that the College is able to place at the disposal of the Faculty is a very real asset. A new College would take time to amass such assets but i t could be done. In the meantime, many Fellows of the Faculty are already Members of the College of Surgeons which at least gives them access to the Library. Many also have access to the libraries at the British Medical Association, The Royal Society of Medicine, the Royal College of Physicians of London and those of other prestigious colleges and institutions. It is, however, true that there would be a reduction in other available facilities and in charitable income. This has to be setagainst the benefits of independence. What are these benefits? Currently we are Fellows in the Faculty of the Royal College of Surgeons of England. No further changes in the charter are likely are likely to alter that fact. The College is a College of Surgeons; it always has been and, in my view, should always remain so. The compromise view, once advocated, of a College of Surgical Sciences with three faculties, Surgery, Dental Surgery and Anaesthesia, is unlikely to find favour with our surgical colleagues, and why should it? Independence is only meaningful once it can be seen, and it cannot be seen until there is a College of Anaesthetists. Such a college can be strong, can grow in stature and can control its own financial and academic destiny. It can, however, only be achieved by a united speciality. The speciality is currently divided in opinion and more time is necessary for discussion, debate and education. There is no hurry. It took the surgeons two hundred years to separate from the barbers. I don’t have that much time but another two or three years is not too long to wait! Let us not be ashamed to voice our opinions, discuss our views and seek a consensus. Only when discussion becomes inhibited and the subject taboo d o we really have cause to worry. Therefore I should like to congratulate the Dean on opening up the discussion, on voicing his personal views and reservations and for the moderate manner in which he has approached the subject. I have tried to emulate his example and sincerely hope that others will d o the same. Department of Anaesthetics, Frenchay Hospital, Bristol BS16 ILE
JOHN ZORAB
Correspondence
eliminated but may have been temporarily stemmed by the introduction of the EM1 scan), and coronary artery surgery has recently added another burden to the already heavy load in cardiothoracic units. Transplant surgery, the increasing demand for anaesthetic staff for obstetric units and pain relief by epidural injections constitute yet other groups of cases where additional anaesthetic help is required. The amount of work which can be done in Pain Clinics is an area where the demands on anaesthetists are substantially insatiable. In Intensive Care Units anaesthetists do not only deal with critically ill patients and administer the units. In some parts of the country they have become theclinicians who carry the main burden of looking after cases of poisoning and head injuries, as latter are now all too often admitted to Intensive Care Units in hospitals where there is no neurosurgical service. It is therefore not surprising that there is a shortage of anaesthetists to meet these so rapidly expanding demands. The North West Regional Health Authority provides an example of the shortage. It has under consideration sixteen unsatisfied applications from Area Health Authorities for additional consultant anaesthetists. In the year 1976/77 one additional consultant anaesthetist appointment was authorised by the Department of Health and Social Security (DHSS) and in 1977/78 one further appointment was authorised. Even existing anaesthetic establishments are not being fully filled; for example Trent Region recently had thirteen consultant vacancies which have been advertised and for which there have been no suitable applicants. The DHSS, from the statistics supplied to them by the Areas reckon that there are 41 vacant consultant posts in England and Wales. A further 82 are filled by locums but many of these are only a few sessions and are inherently unattractive. Perhaps the best measure of the shortage is the fact that 30 consultant posts failed to attract a suitably qualified applicantin the last year for which statistics are available. The number of senior registrars in training in England and Wales is approximately 280. Therefore, if the senior registrars spend three years each in the
grade, some 90 should be available for consultant appointments in each year. In fact, according to the calculations of the DHSS, in the year ending April 1978 there were only 60 senior registrars available to take up consultant appointments. In order words, thirty senior registrars had been lost to the Health Service from that particular year’s generation. It is possible to go further back into the situation. Recruitment to the senior registrar grade depends on the obtaining of the FFARCS qualification. Nearly 200 pass the final examination for the FFARCS in England alone each year, and there are an appreciable number who successfully sit the FFARCS of the Royal College of Surgeons in Ireland. In short, there are some 200 potential senior registrar applicants in England during each year, including some Scots, and of these no more than about 100 become senior registrars, and not infrequently there is only one applicant for a less attractive post. The remainder, with the exception of some 20 who become Senior Registrars either in Scotland or Northern Ireland, are lost to the service. Why there should be this tremendous wastage is by no means clear. It is certainly possible that some of those who sit the final FFARCS are married women who elect to start a family on passing the examination. A small proportion of those who pass the examination come from abroad, specifically to complete their training in the United Kingdom, and return whence they came. Others no doubt decide that consultant practice is not attractive and opt for general practice, and yet others emigrate. But, even taking into account those possible causes of loss, the fact that something like 50% of those who pass the FFARCS examination, and are therefore eligible for senior registrarships in the United Kingdom, actually choose to apply for these, must cause grave concern, and might well be a profitable matter for further investigation. Department of Anaesthetics, The Royal Infirmary, Manchester M I 3 9 WL
A.R. HUNTER
A College of Anaesthetists? May I, through the courtesy of your columns, comment on the September 1978 Newsletter from the Dean of the Faculty of Anaesthetists, Royal College of Surgeons? While Newsletters are not, perhaps, intended to provoke replies, that written by the Dean sets out his personal views on the Faculty/ Independent College controversy and I, as an ordinary Member of the Board, would like the opportunity to express my own. May I first draw attention to the following
sentence in the Newsletter: ‘Whatever changes are to take place in the future, whether these occur within the College or outside it, let it clearly be understood by all Fellows and Members, that those changes can only be initiated from within the Faculty and in consultation with the Faculty’s present partners in the College.’ There is no doubt in my mind that change is still needed and that, eventually, that change will require the creation of an independent College of
Correspondence Anaesthetists. There is equally no doubt in my mind that that change, when it comes, must stem from a majority within the Board of Faculty. Thus, I find myself in total agreement with the Dean when he says, ‘If the Board of Faculty decides that the objects for which the faculty exists would be better promoted in a separate ccllege, then its responsibility is to inform the Fellows of that view and to tell them how it can be achieved’, indeed, the only improvement I could make to that sentence is to change the initial ‘If’ to ‘When’! May I now comment on some other aspects of the Dean’s Newsletter? I cannot share the Dean’s depression and disappointment at the way in which the debate about a future independent college of anaesthetists has been conducted; to me, it is a sign of a very healthy speciality that it should concern itself with those organisations that govern its future. It is true that much of the debate has been promoted by the Association of Anaesthetists but the Faculty has not only been perfectly free to take part but positively invited to do so on more than one occasion. Indeed, I welcome the current Newsletter both for its reasoned and moderate tone and its attempt to set out the benefits of staying within the Royal College of Surgeons. Many of these benefits are very real and I would certainly not wish to deny them. Others, however, are questionable. ‘We are currently part of an active and powerful College: to be independent and weak is not necessarily preferable to being strong in a state of mutual independence.’ This is a very forceful argument but who has ever advocated the creation of an independent and weak college? We are the largest single speciality in the country. What is to stop a College of Anaesthetists being independent and strong? ‘The evolution of the academic organisation of anaesthesia in isolation from surgery is as unthinkable as the evolution of surgery in isolation from anaesthesia.’ Why, one asks, does the creation of an independent college of anaesthetists isolate us from surgery? Is it so difficult for sister colleges to work together? Might not our relationships with the College of Obstetricians and Gynaecologists and the College of Physicians be improved if we were all on an equal footing? The Dean notes that the Faculty is now independent within the College Constitution. Functionally, I have no doubt that this is true although purists might argue that, without financial independence, there can be no true independence. The claim that politicians can easily ignore a succession of independent and conflicting claims is very true. But is independence a reason for conflict, and, in any case,
73
the Conference of Royal Colleges and Faculties has succeeded in giving a corporate voice to all collegiate institutions. The resources that the College is able to place at the disposal of the Faculty is a very real asset. A new College would take time to amass such assets but i t could be done. In the meantime, many Fellows of the Faculty are already Members of the College of Surgeons which at least gives them access to the Library. Many also have access to the libraries at the British Medical Association, The Royal Society of Medicine, the Royal College of Physicians of London and those of other prestigious colleges and institutions. It is, however, true that there would be a reduction in other available facilities and in charitable income. This has to be setagainst the benefits of independence. What are these benefits? Currently we are Fellows in the Faculty of the Royal College of Surgeons of England. No further changes in the charter are likely are likely to alter that fact. The College is a College of Surgeons; it always has been and, in my view, should always remain so. The compromise view, once advocated, of a College of Surgical Sciences with three faculties, Surgery, Dental Surgery and Anaesthesia, is unlikely to find favour with our surgical colleagues, and why should it? Independence is only meaningful once it can be seen, and it cannot be seen until there is a College of Anaesthetists. Such a college can be strong, can grow in stature and can control its own financial and academic destiny. It can, however, only be achieved by a united speciality. The speciality is currently divided in opinion and more time is necessary for discussion, debate and education. There is no hurry. It took the surgeons two hundred years to separate from the barbers. I don’t have that much time but another two or three years is not too long to wait! Let us not be ashamed to voice our opinions, discuss our views and seek a consensus. Only when discussion becomes inhibited and the subject taboo d o we really have cause to worry. Therefore I should like to congratulate the Dean on opening up the discussion, on voicing his personal views and reservations and for the moderate manner in which he has approached the subject. I have tried to emulate his example and sincerely hope that others will d o the same. Department of Anaesthetics, Frenchay Hospital, Bristol BS16 ILE
JOHN ZORAB
