Current Newsletter

Mr John Black, President

We enter the second decade

Ann R Coll Surg Engl (Suppl) 2010; 92:42-43

I wonder how many royal college presidents have ever been in the UNISON building on the Euston Road? I suspect I may have been the first when I went there recently to address their medical secretaries' group and to take part in a panel discussion. The loss of consultant surgeons' personal secretaries that has occurred in many NHS hospitals over the last ten years is deplorable. It is a common event when a hospital moves to a new site or a new building that individual office accommodation for consultants and their secretaries is forgotten or even worse, that many of the tasks are outsourced abroad.

Why has it happened? It is easy to say that it is cost-cutting but with the billions of pounds that have been thrown at the NHS in recent years it is difficult to see that it is necessary. Nearly every manager seems to have an office and a secretary so why not consultants and their secretaries? The UNISON medical secretaries supported this view.

I believe that the Prime Minister himself deplores the fact that all the money spent on the NHS since 1997 has not improved surgical 'productivity'. When is the penny going to drop that the transfer of day-to-day management of patient referrals and admissions away from individual consultants and their secretaries to Choose and Book and pooled waiting lists has resulted in massive inefficiency? Did the operating list contain potentially dangerous errors, all taking time to sort out, when the personal secretary of the operating surgeon produced it? Should not the waiting list be ordered by clinical priority and not interfered with arbitrarily by people with no clinical knowledge or insight, terrified that there might be a 'breach'?

There was a time when surgeons worked far more efficiently and treated patients in the right order and the linchpin in that system was the medical secretary. Perhaps if NHS money was spent more wisely we could have short waiting lists through higher productivity, not by consuming more resources. The secretary was also the principal contact for individual patients, who could ring up and talk to somebody who knew about them and could get their problems dealt with by the consultant and his or her team. Many hospital trusts these days have sizeable communications departments. The people they should be communicating with are their own patients on an individual level to make the service better fit their needs. The best person to do that is the consultant's personal medical secretary who knows him or her by name.

What can we do about it? Nationally the College campaigns for the highest standards of patient care and the thread running through it is continuity of care. Patients want to see their own GP and when referred to hospital to see the same consultant team throughout the episode, either emergency or elective. To achieve that Choose and Book, meant to increase patient choice but in practice achieving the opposite by removing personal consultant/GP relationships, must be replaced by a referral system personal to the patient.

What can you do about it? Please stand up for your secretaries, turn up for the management meetings when their future is discussed and point out how essential they are to safe, efficient surgical care with a human face.

Returning to my theme of continuity of care, the European Working Time Directive (EWTD) has led to the junior doctors previously seen by patients as 'their' doctors throughout their stay in hospital becoming in the words of the latest report from the National Confidential Enquiry into Patient Outcome and Death, Caring to the End?, 'transient acquaintances during a patient's illness rather than having responsibility for continuity of care'.¹ The College will campaign against the EWTD until there is an opt-out for surgeons, however long it takes. I recently emailed the College membership asking you all to lobby your MPs and parliamentary candidates and I am grateful to those who have done so. The solution requires political will and political will is created by angry and persistent constituents!

There was some good news recently about the introduction of revalidation in 2011. I have been pressing for piloting an initially very simple process, which will not involve too much of surgeons' time and which can be added to as necessary. This approach is favoured by the other royal colleges too.

We do not want another MTAS [Medical Training Application Service], where an untried national computer-based system of Byzantine complexity not surprisingly failed at the first test. Revalidation is an essentially simple process in which the individual doctor demonstrates to the General Medical Council (GMC) his or her continued ability to practise. This is done to standards set by the royal college (work already done for the surgical specialties by the specialty associations facilitated by the college) and clearly the individual employer, either NHS or private sector, will want to make sure that things run efficiently.

We have suggested some surgical pilots of this slimmed-down approach and at a recent meeting with Professor Peter Rubin, Chairman of the GMC, and Dr Hugo Mascie-Taylor, Medical Director of NHS Employers, it was agreed that we go ahead with some pilots in 2010, in two or three surgical specialties in two or three strategic health authorities. Surgeons are in some ways easier to revalidate than other specialties as we have a measurable procedure-based workload and it is good that we will be leading the way.

1. National Confidential Enquiry into Patient Outcome and Death. Caring to the End? A review of the care of patients who died in hospital within four days of admission. London: NCEPOD; 2009.

23 December 2009