502 Proc. roy. Soc. Med. Volume 68 August 1975
journal and a general declaration that the doctor proposes to return to medicine. In addition the doctor undertakes to do at least seven sessions per annum in postgraduate education and twelve paid sessions a year in the specialty and at the time of her choice. This enlightened scheme has so far attracted about 250 women and has kept them feeling they are still doctors. It is interesting that quite a number have found they can do more than the maximum two sessions a week and they move into the next scheme. This was introduced in 1969 under RHB(69)6 (HM69)6 and SHM 14/1969) and provides for part-time training for doctors who cannot for personal and domestic reasons undertake wholetime work. It operates on every level from house officer to senior registrar but in the later stages involves at least a half time commitment to medicine and a willingness to take their share of emergency and weekend duty. The educational content has to be approved by the appropriate authority and the manpower angle is looked at by the profession and the department. This excellent scheme works well, though now rather cumbrously because of all the necessary hurdles which have to be crossed. The Medical Women's Federation has sought to complement the Clinical Tutors and Regional Postgraduate machinery by approving 'a new network of Liaison Officers who offer help and advice to women who are undecided about what they should do. This works very well in some areas and hardly at all in others. A further problem of what happens when the women have completed training is a difficult one, but it is not a subject for this meeting. These schemes should in theory meet the needs of those who need special consideration. The others will stand quite successfully on their own feet. I hope that what I have said will persuade you from excluding women from the profession and from arguing that it does not pay to train them. REFERENCES
Department of Health and Social Security (1974) Health and Personal Social Services Statistics in England 1974. HMSO, London
Flynn C A & Gardner F (1969) British Journal of Medical Education 3, 128 Interdepartmental Committee (Goodenough) on Medical Schools
(1944) Report. HMSO, London Jefferys M & Elliott P M (1966) Women in Medicine. Office of Health Economics, London Lawrie J E, Newhouse M L & Elliott P M (1966) British Medical Journal i, 409 Lutzker E (1969) Women Gaia a Place in Medicine. McGraw Hill, New York Manton J (1965) Elizabeth Garrett Anderson. Methuen, London Mead K C H (1938) Women in Medicine. Haddon Press, Haddon Rae I (1958) The Strange Story of Dr James Barry. Longmans, Green & Co, London Royal Commission on Medical Education (Todd) (1968) Report. Cmnd. 3569. HMSO, London
8
Mr D E Bolt
,(West Middlesex Hospital, Isleworth)
How Many Doctors? Changing Contractural Situations
When the National Health Service came into existence, in 1948, the contracts offered to its medical staff were strikingly ill-defined. While consultant contracts were based, nominally, upon 'notional half-days' it was implicit that, for a specified salary, the consultant would provide all the professional services his situation demanded, with no additional remuneration apart from fees for domiciliary consultations and the benefits of a distinction award, if he was fortunate enough to be given one. The same pattern applied, in principle, to the contracts of general practitioners and junior medical staff in hospital. With a slow rate of inflation, reasonable and regular adjustments of salary and a fairly stable work-load, this type of arrangement might have continued indefinitely but the combination of rapidly declining money values, inadequately compensated by increases in payment, escalating workloads and the frequent appearance of new tasks, never envisaged in the original contracts, produced an increasing demand for 'closed contracts'. The Closed Contract Essentially, the idea underlying this type of contract is that the amount of work for which the service is paying in the basic salary should be defined, so that additional items beyond this could be identified and paid for. The first move in this direction was made by the general practitioners in their 'Charter for the Family Doctor Service' negotiated in 1965. In this contract, the emergency element in their work, outside normal working hours, was separated from their other responsibilities and separately remunerated. In theory, each general practitioner was at liberty to exclude the emergency element from his contract but, as he would then be required to find another practitioner in his vicinity willing to provide the emergency service for the appropriate remuneration, the option was more apparent than real. However, it can be argued that the fact that the payment for providing emergency cover was greater than the cost to the practitioner of employing an emergency call service, where one existed, contributed to the growth of these services, in effect attracting additional medical manpower into the general practice field, much of it provided by junior hospital medical staff. The junior hospital medical staff approached the problem of closing their contracts from the
9
Section ofMedical Education
opposite direction by obtaining recognition of a certain minimum level of off-duty entitlement, invasion of which required payment of extra duty allowances, originally activated after 108 hours of work in a week, more recently after 80 hours. In January 1975 agreement was reached, in principle, to a further modification of their contracts, introducing the concept of individually designed contracts for each junior, specifying on appointment the hours to be worked and the pattern of work to be undertaken. These new contracts will be based upon a 40 hour week, with up to 40 additional hours to be worked, the precise distribution of pay between the two segments to be determined by the impending report by the Doctors and Dentists Review Body. Since it will be possible for juniors to work beyond the 80 hours, in return for extra duty payments, these changes have no inevitable consequences for medical manpower requirements but it will become increasingly expensive to use such manpower inefficiently, with possible effects upon the quality of service offered. It seems inevitable that there will be pressure to reduce the number of staff on duty at night and weekends, making cover thinner and possibly creating the need for cross-cover of units by juniors in other related specialties. It seems unavoidable that work in small units and hospitals and in those with a particularly heavy emergency load must suffer. Since the late 1960s, there has been mounting interest among consultants in the concept of a closed contract. This may seem an undesirable attitude but it must be remembered that the pattern of practice within the consultant body varies more profoundly than people in major centres realize. The effect upon the quality of a consultant's life of the availability of adequate junior staff is profound. There are many consultants, up and down Great Britain, providing major emergency services on alternate nights and alternate weekends, with junior staff to whom it would be quite improper to delegate the care of seriously ill people. Such consultants are bearing an unfair burden without any financial or other recompense and it was from them, most of all, that the demand for a closed contract originated. Proposals to this end were first presented to the Department of Health in August 1972 and led, eventually, to the ill-fated Owen Working Party. The tragic events of 20 December 1974, when the profession saw, for the first time, the kind of contract which could result from the demand for closure, produced not only overwhelming rejection of the Secretary of State's proposals but also increasing doubt, within the profession, about the wisdom of seeking a closed contract, in any form.
What is the Profession Seeking? It seems that the profession is, essentially, seeking three things:
503
(1) After a long period of statutory wage control, effectively enforced upon it, in an inflationary situation, the profession is seeking more money. If this may seem slightly improper in a dedicated profession, the realization that consultants, nominally contracted for 311 or 381 hours weekly, are working, on average, between 59 and 64 hours, with an addition of between 51 and 55 hours on-call, may modify this impression. Indeed, a glance at salary scales in other advanced countries and the realization that there is an international market in medical skills, may make it seem an urgent necessity that the search should be successful. (2) It is also clear that the profession is seeking an improved quality of life. There seems no valid reason why, in a world of increasing leisure and recreational opportunity, consultants generally should not share in such opportunities. The diminishing field of applicants for prestigious appointments in big conurbations and the increasing numbers seeking peripheral posts, in pleasant surroundings, with lighter work-loads, tells this story.
(3) Consultants are also seeking a better Health Service. At this time, probably between 60 % and 70% of them have deliberately reduced their work-loads. They are rediscovering the satisfaction of practising to the standards they were taught. They are giving adequate time to each consultation, talking to their patients as humanity requires, doing careful unhurried surgery and seeing patients recover in their wards, instead of hurrying them out, as soon as they can stand. They and all their staffs, relieved from much of the pressure of 'normal' working, want to'see this pattern of hospital life continued. This is the sort of National Health Service they are seeking. When the political clouds have lifted, will the National Health Service ever be the same again? Will consultants ever return to the old pattern?* If not, can the term 'comprehensive' still be applied to a Health Service which, in large areas of the country, will be providing service to emergency and urgent cases only ?
Implicationsfor the Future The National Health Service cannot survive as an effective institution with a chronically dissatisfied consultant body. Already, all the evidence points to a rising tide of emigration and, even if it would be acceptable to solve the problem of manpower loss by employment of immigrant
504 Proc. roy. Soc. Med. Volume 68 August 1975
10
labour, the report of the Merrison Committee must surely make permanent practice here by overseas doctors conditional upon obtaining a British qualification. We cannot continue indefinitely staffing the National Health Service at the expense of less well-endowed communities. Figures indicating the scale of emigration are notoriously difficult to obtain and always out-ofdate but in 1974 alone, the State of Manitoba permanently registered 51 British medical graduates, twice the figure for ten years previously and between one-third and one-half of the annual output of a British medical school. Remuneration alone does not take British graduates abroad. Adequate facilities and the opportunity to work to high standards, with a reasonable work-load, are factors no less potent than salary in attracting our medical staff abroad and the problem cannot be dealt with on a contract basis alone. It is possible to envisage two different patterns of development for the future, both of which have profound implications for manpower requirements. The present consultant body has become acutely aware of the hazards of the closed contract and is now seeking modifications in the present contract, designed to relate returns more closely to work-load and perhaps, in the long run, to create a more equitable distribution of burdens. If this target is to be met, the present average working week of consultants must be brought within reasonable limits. Even assuming no significant increase in demand upon the service, the achievement of an average 40 hour week for consultants must imply an increase of 30 % in the establishment, with the appropriate increase in junior staff. Since it is essential, if the desired effect is to be achieved, that the increase in staff should be predominantly composed of British graduates, the expected results of the Todd proposals must be woefully inadequate. Nevertheless, if the objective is to be a comprehensive National Health Service providing a high standard of care, such expansion is essential. However, the views of the present generation of senior staff on future working patterns may prove wholly irrelevant. It may well be that a generation of junior staff brought up within the system of defined contracts such as are at present being implemented may, on reaching consultant status, accept the logical development of such contracts, which appears to be the whole-time salaried service. In this event, the implications for manpower requirements are difficult to anticipate. There would certainly be administrative action to
rationalize the pattern of work, both inside and outside hospital, particularly in the emergency context, with economy in manpower at the expense of the high degree of personal service now provided to patients. The distinction between career and training grades must surely become blurred and the 'subconsultant grade' so long anathema to the profession become a reality. Such changes would modify manpower needs, the efficient deployment of doctors tending to off-set somewhat the increased numbers needed to reduce work-loads and give adequate off-duty. However, experience in Sweden, where contractural arrangements for doctors have much in common with the new contracts for junior hospital staff now being implemented, shows that such radical changes produce unexpected effects, not invariably favouring manpower economy. Swedish consultants, who can claim additional money for on-call and emergency duties, find that the impact of high taxation is such that the money is not worth collecting. Instead, they commonly elect to take additional leave in lieu of such payments, a practice which has caused the authorities to employ 1.3 consultants for each post in their service, to allow adequate cover during prolonged absence. It is by no means certain that the efficiency potentially resulting from the employment of all medical staff on a whole-time salaried basis would allow any significant reduction in the total numbers for which the National Health Service must budget if the service is to be both comprehensive and good. Since the target of a first-class National Health Service, offering a comprehensive medical service of high quality to the whole population, is common to the profession, the Department of Health and the relevant Ministers, it is essential that the problems of contracts are solved. The service cannot be run successfully by a discontented consultant body. The manpower implications of giving the consultants a satisfactory personal and professional life are enormous and exceedingly costly. Nothing in recent experience suggests that the necessary money will be forthcoming, under the present system of financing. The need to rethink this fundamental issue is overwhelming but, regrettably, so intimately is the National Health Service linked to politics, that even to say such a thing may be taken to imply a political attitude. Most of all, the Service needs to be freed from its political associations.
journal and a general declaration that the doctor proposes to return to medicine. In addition the doctor undertakes to do at least seven sessions per annum in postgraduate education and twelve paid sessions a year in the specialty and at the time of her choice. This enlightened scheme has so far attracted about 250 women and has kept them feeling they are still doctors. It is interesting that quite a number have found they can do more than the maximum two sessions a week and they move into the next scheme. This was introduced in 1969 under RHB(69)6 (HM69)6 and SHM 14/1969) and provides for part-time training for doctors who cannot for personal and domestic reasons undertake wholetime work. It operates on every level from house officer to senior registrar but in the later stages involves at least a half time commitment to medicine and a willingness to take their share of emergency and weekend duty. The educational content has to be approved by the appropriate authority and the manpower angle is looked at by the profession and the department. This excellent scheme works well, though now rather cumbrously because of all the necessary hurdles which have to be crossed. The Medical Women's Federation has sought to complement the Clinical Tutors and Regional Postgraduate machinery by approving 'a new network of Liaison Officers who offer help and advice to women who are undecided about what they should do. This works very well in some areas and hardly at all in others. A further problem of what happens when the women have completed training is a difficult one, but it is not a subject for this meeting. These schemes should in theory meet the needs of those who need special consideration. The others will stand quite successfully on their own feet. I hope that what I have said will persuade you from excluding women from the profession and from arguing that it does not pay to train them. REFERENCES
Department of Health and Social Security (1974) Health and Personal Social Services Statistics in England 1974. HMSO, London
Flynn C A & Gardner F (1969) British Journal of Medical Education 3, 128 Interdepartmental Committee (Goodenough) on Medical Schools
(1944) Report. HMSO, London Jefferys M & Elliott P M (1966) Women in Medicine. Office of Health Economics, London Lawrie J E, Newhouse M L & Elliott P M (1966) British Medical Journal i, 409 Lutzker E (1969) Women Gaia a Place in Medicine. McGraw Hill, New York Manton J (1965) Elizabeth Garrett Anderson. Methuen, London Mead K C H (1938) Women in Medicine. Haddon Press, Haddon Rae I (1958) The Strange Story of Dr James Barry. Longmans, Green & Co, London Royal Commission on Medical Education (Todd) (1968) Report. Cmnd. 3569. HMSO, London
8
Mr D E Bolt
,(West Middlesex Hospital, Isleworth)
How Many Doctors? Changing Contractural Situations
When the National Health Service came into existence, in 1948, the contracts offered to its medical staff were strikingly ill-defined. While consultant contracts were based, nominally, upon 'notional half-days' it was implicit that, for a specified salary, the consultant would provide all the professional services his situation demanded, with no additional remuneration apart from fees for domiciliary consultations and the benefits of a distinction award, if he was fortunate enough to be given one. The same pattern applied, in principle, to the contracts of general practitioners and junior medical staff in hospital. With a slow rate of inflation, reasonable and regular adjustments of salary and a fairly stable work-load, this type of arrangement might have continued indefinitely but the combination of rapidly declining money values, inadequately compensated by increases in payment, escalating workloads and the frequent appearance of new tasks, never envisaged in the original contracts, produced an increasing demand for 'closed contracts'. The Closed Contract Essentially, the idea underlying this type of contract is that the amount of work for which the service is paying in the basic salary should be defined, so that additional items beyond this could be identified and paid for. The first move in this direction was made by the general practitioners in their 'Charter for the Family Doctor Service' negotiated in 1965. In this contract, the emergency element in their work, outside normal working hours, was separated from their other responsibilities and separately remunerated. In theory, each general practitioner was at liberty to exclude the emergency element from his contract but, as he would then be required to find another practitioner in his vicinity willing to provide the emergency service for the appropriate remuneration, the option was more apparent than real. However, it can be argued that the fact that the payment for providing emergency cover was greater than the cost to the practitioner of employing an emergency call service, where one existed, contributed to the growth of these services, in effect attracting additional medical manpower into the general practice field, much of it provided by junior hospital medical staff. The junior hospital medical staff approached the problem of closing their contracts from the
9
Section ofMedical Education
opposite direction by obtaining recognition of a certain minimum level of off-duty entitlement, invasion of which required payment of extra duty allowances, originally activated after 108 hours of work in a week, more recently after 80 hours. In January 1975 agreement was reached, in principle, to a further modification of their contracts, introducing the concept of individually designed contracts for each junior, specifying on appointment the hours to be worked and the pattern of work to be undertaken. These new contracts will be based upon a 40 hour week, with up to 40 additional hours to be worked, the precise distribution of pay between the two segments to be determined by the impending report by the Doctors and Dentists Review Body. Since it will be possible for juniors to work beyond the 80 hours, in return for extra duty payments, these changes have no inevitable consequences for medical manpower requirements but it will become increasingly expensive to use such manpower inefficiently, with possible effects upon the quality of service offered. It seems inevitable that there will be pressure to reduce the number of staff on duty at night and weekends, making cover thinner and possibly creating the need for cross-cover of units by juniors in other related specialties. It seems unavoidable that work in small units and hospitals and in those with a particularly heavy emergency load must suffer. Since the late 1960s, there has been mounting interest among consultants in the concept of a closed contract. This may seem an undesirable attitude but it must be remembered that the pattern of practice within the consultant body varies more profoundly than people in major centres realize. The effect upon the quality of a consultant's life of the availability of adequate junior staff is profound. There are many consultants, up and down Great Britain, providing major emergency services on alternate nights and alternate weekends, with junior staff to whom it would be quite improper to delegate the care of seriously ill people. Such consultants are bearing an unfair burden without any financial or other recompense and it was from them, most of all, that the demand for a closed contract originated. Proposals to this end were first presented to the Department of Health in August 1972 and led, eventually, to the ill-fated Owen Working Party. The tragic events of 20 December 1974, when the profession saw, for the first time, the kind of contract which could result from the demand for closure, produced not only overwhelming rejection of the Secretary of State's proposals but also increasing doubt, within the profession, about the wisdom of seeking a closed contract, in any form.
What is the Profession Seeking? It seems that the profession is, essentially, seeking three things:
503
(1) After a long period of statutory wage control, effectively enforced upon it, in an inflationary situation, the profession is seeking more money. If this may seem slightly improper in a dedicated profession, the realization that consultants, nominally contracted for 311 or 381 hours weekly, are working, on average, between 59 and 64 hours, with an addition of between 51 and 55 hours on-call, may modify this impression. Indeed, a glance at salary scales in other advanced countries and the realization that there is an international market in medical skills, may make it seem an urgent necessity that the search should be successful. (2) It is also clear that the profession is seeking an improved quality of life. There seems no valid reason why, in a world of increasing leisure and recreational opportunity, consultants generally should not share in such opportunities. The diminishing field of applicants for prestigious appointments in big conurbations and the increasing numbers seeking peripheral posts, in pleasant surroundings, with lighter work-loads, tells this story.
(3) Consultants are also seeking a better Health Service. At this time, probably between 60 % and 70% of them have deliberately reduced their work-loads. They are rediscovering the satisfaction of practising to the standards they were taught. They are giving adequate time to each consultation, talking to their patients as humanity requires, doing careful unhurried surgery and seeing patients recover in their wards, instead of hurrying them out, as soon as they can stand. They and all their staffs, relieved from much of the pressure of 'normal' working, want to'see this pattern of hospital life continued. This is the sort of National Health Service they are seeking. When the political clouds have lifted, will the National Health Service ever be the same again? Will consultants ever return to the old pattern?* If not, can the term 'comprehensive' still be applied to a Health Service which, in large areas of the country, will be providing service to emergency and urgent cases only ?
Implicationsfor the Future The National Health Service cannot survive as an effective institution with a chronically dissatisfied consultant body. Already, all the evidence points to a rising tide of emigration and, even if it would be acceptable to solve the problem of manpower loss by employment of immigrant
504 Proc. roy. Soc. Med. Volume 68 August 1975
10
labour, the report of the Merrison Committee must surely make permanent practice here by overseas doctors conditional upon obtaining a British qualification. We cannot continue indefinitely staffing the National Health Service at the expense of less well-endowed communities. Figures indicating the scale of emigration are notoriously difficult to obtain and always out-ofdate but in 1974 alone, the State of Manitoba permanently registered 51 British medical graduates, twice the figure for ten years previously and between one-third and one-half of the annual output of a British medical school. Remuneration alone does not take British graduates abroad. Adequate facilities and the opportunity to work to high standards, with a reasonable work-load, are factors no less potent than salary in attracting our medical staff abroad and the problem cannot be dealt with on a contract basis alone. It is possible to envisage two different patterns of development for the future, both of which have profound implications for manpower requirements. The present consultant body has become acutely aware of the hazards of the closed contract and is now seeking modifications in the present contract, designed to relate returns more closely to work-load and perhaps, in the long run, to create a more equitable distribution of burdens. If this target is to be met, the present average working week of consultants must be brought within reasonable limits. Even assuming no significant increase in demand upon the service, the achievement of an average 40 hour week for consultants must imply an increase of 30 % in the establishment, with the appropriate increase in junior staff. Since it is essential, if the desired effect is to be achieved, that the increase in staff should be predominantly composed of British graduates, the expected results of the Todd proposals must be woefully inadequate. Nevertheless, if the objective is to be a comprehensive National Health Service providing a high standard of care, such expansion is essential. However, the views of the present generation of senior staff on future working patterns may prove wholly irrelevant. It may well be that a generation of junior staff brought up within the system of defined contracts such as are at present being implemented may, on reaching consultant status, accept the logical development of such contracts, which appears to be the whole-time salaried service. In this event, the implications for manpower requirements are difficult to anticipate. There would certainly be administrative action to
rationalize the pattern of work, both inside and outside hospital, particularly in the emergency context, with economy in manpower at the expense of the high degree of personal service now provided to patients. The distinction between career and training grades must surely become blurred and the 'subconsultant grade' so long anathema to the profession become a reality. Such changes would modify manpower needs, the efficient deployment of doctors tending to off-set somewhat the increased numbers needed to reduce work-loads and give adequate off-duty. However, experience in Sweden, where contractural arrangements for doctors have much in common with the new contracts for junior hospital staff now being implemented, shows that such radical changes produce unexpected effects, not invariably favouring manpower economy. Swedish consultants, who can claim additional money for on-call and emergency duties, find that the impact of high taxation is such that the money is not worth collecting. Instead, they commonly elect to take additional leave in lieu of such payments, a practice which has caused the authorities to employ 1.3 consultants for each post in their service, to allow adequate cover during prolonged absence. It is by no means certain that the efficiency potentially resulting from the employment of all medical staff on a whole-time salaried basis would allow any significant reduction in the total numbers for which the National Health Service must budget if the service is to be both comprehensive and good. Since the target of a first-class National Health Service, offering a comprehensive medical service of high quality to the whole population, is common to the profession, the Department of Health and the relevant Ministers, it is essential that the problems of contracts are solved. The service cannot be run successfully by a discontented consultant body. The manpower implications of giving the consultants a satisfactory personal and professional life are enormous and exceedingly costly. Nothing in recent experience suggests that the necessary money will be forthcoming, under the present system of financing. The need to rethink this fundamental issue is overwhelming but, regrettably, so intimately is the National Health Service linked to politics, that even to say such a thing may be taken to imply a political attitude. Most of all, the Service needs to be freed from its political associations.
