Postgraduate Medical Education - response

Campaign for Health Service Democracy

Sheila Porter-Williams,
Green Haven,
Halfway Lane,
Dunchurch,
Rugby,
Warwickshire,
CV22 6RD

28 December, 2001

Kenneth Allen
MESB
Education and Training Directorate
Department of Health
Room 2E43, Quarry House, Quarry Hill
Leeds LS2 7UE

Dear Mr Allen,

The Campaign for Health Service Democracy was formed in 1997 when my mother was contemptuously refused emergency surgery for a broken hip and there was no procedure within the hospital for reviewing or appealing against the consultant’s decision. We aim to bring about local democratic accountability of staff working in the health service and of policies applied locally.

We broadly support the proposals in the Consultation Paper. We would prefer directly elected rather than appointed boards, but our priorities for these are the Primary Care Trusts and NHS Trusts providing services locally. When such bodies are elected, regional and national bodies including the Medical Education Standards Board should consist mainly of representatives of these local bodies.

The following comments relate to particular paragraphs.

23. We agree with this summary, especially with the last point. There is always likely to be a tension between the medical profession and people needing medical attention.
    
    The medical profession seeks greater and greater degrees of specialisation of staff and concentration of the most effective equipment at large hospitals achieving the highest success rates.
    
    Public views, as demonstrated in the campaign to save the St Cross Hospital in Rugby, and even more conspicuously with the election of Dr Richard Taylor as MP for Wyre Forest, give much more emphasis to accessible services. This applies particularly to accident and emergency departments, but the need extends much wider. People who are seriously ill should not need to be transferred between hospitals. With the growing trend towards day surgery and early discharge, patients need the shortest practicable journey home, and the shortest practicable journey for readmission if complications develop. Concentration of services at remote specialist centres is only publicly acceptable when there are legitimate reasons for higher success rates at the specialist centres. At present this seems to apply to cancer treatment.
    
    It is unhelpful for NHS managers to use (as they do) the Royal Colleges’ objections to lack of sufficient caseload in a sub-specialty as an excuse for confirming unpopular decisions to close local hospital services. In some instances other solutions can be found, whether by teams of staff contracted for sessions at each of a group of hospitals or by combining sub-specialties for the less complicated cases handled at local hospitals or by GPs taking over the local work abandoned by the hospitals. Decisions requiring proactive solutions to conflicts between legitimately held views need to be taken by people representative of the communities they serve. As the needs of postgraduate medical education form part of the conflict, a Medical Education Standards Board that is less embedded in the Royal Colleges should assist in reaching more publicly acceptable solutions.

30. We would agree with the summary of weaknesses in the present system, especially the lack of flexibility and unclear accountability.

38. We agree with the aims in this paragraph.

39. We agree with your reasons for not making the Medical Education Standards Board part of the General Medical Council.

42. We agree with your comments about the Royal Colleges.

52. The membership of the Medical Education Standards Board should be publicly accountable. In part this can be achieved by meeting in public and publishing (eg in the Internet) all the reports on which decisions are to be made, and by consulting widely on difficult issues where there is conflict between needs of training and convenient service delivery. But this is still a step short of democratic accountability. Until there are directly elected NHS Trusts, some of the membership of the Medical Education Standards Board should be nominated through similar arrangements to those proposed for collaboration between local authority scrutiny committees for scrutiny at Strategic Health Authority level. Each of these members should be indirectly elected to represent a specific region and should be accessible by post, telephone and email to residents of that region.

58. The functions described are quite broad. In order to balance the needs of medical education and the needs of the NHS, it may be necessary to regulate employment of junior doctors. For example all specialist registrars might need to spend some time in centres of excellence and some in less specialised local hospitals, or GP registrars might need to acquire some specialist knowledge that can be used at a local hospital as an alternative to sending patients to a remote hospital.

66. Publicly available registers can only be good. It should be clear what are the limits of an individual doctor’s competence. This could include minor surgery for a GP and could restrict specialists to specific types of surgery. There will need to be scope to extend a doctor’s registration through further training.

78. Quality assurance should include routine publication of each doctor’s death rates. This should highlight extreme malpractice like Harold Shipman and also inappropriate treatments as in Bristol Royal Infirmary.

79. Formally accountability can only be to the Secretary of State. Existing NHS Trusts are also accountable to the Secretary of State, and some of them treat the people they serve with contempt, sheltering their response to issues of public concern behind a cloak of "commercial confidentiality". The Medical Education Standards Board will need to develop a culture of public accountability.

90. The new arrangements should be commissioned as soon as possible, provided that the regional indirectly elected representatives (see my comments on paragraph 52) are included from the start. To achieve this, it may be necessary to time the formation of the Medical Education Standards Board to coincide with the implementation of local authorities’ scrutiny powers.

Yours sincerely,

Sheila Porter-Williams