Professional self respect: rights and responsibilities in the new NHS

British Medical Journal, Oct 24, 1998 by Peter Richards

The NHS faces a widening gap between demands and resources.[1 2] The UK government has promised substantial additional funding over the next three years. In return, it expects doctors to help reshape the delivery of health care. Meanwhile, as a result of the Bristol case[3 4] (in which two surgeons from Bristol were found guilty by the General Medical Council of continuing to operate on children when they knew their death rates were unacceptably high) the public is asking whether doctors can be trusted,[5] and government ministers are murmuring that the medical profession is a law unto itself. Certainly, the public and politicians suspect that doctors cover up their failings, although neither perhaps would go as far as George Bernard Shaw in asserting that "every doctor will allow a colleague to decimate the whole countryside sooner than vitiate the bond of professional etiquette by giving him away."[6]

Accountable professional self regulation

If the process of self regulation is becoming more accountable, transparent, and effective, it surely is in the public interest; who else is in a position to regulate the medical profession more effectively than doctors themselves? But the process must acknowledge public concern that "everything proceeds on the basis of the particular doctor's judgment. It all boils down to the doctor being good, gentle and kind. It would be nice if all doctors were like this. But, just in case, can we not have some more certain guarantees that our interests, as defined by us, may be allowed to prevail?"[7]

Three recent milestones put prospects for responsible self regulation in a positive light. Firstly, the General Medical Council has set clear guidelines on "good medical practice."[8 9] Secondly, the remit of the council has been extended to include the assessment of professional performance,[10 11] and complementary early warning systems to identify doctors in trouble are being introduced at the local level.[12] Thirdly, the process of clinical governance is being introduced throughout the NHS.[13] Additionally, the president of the council is exploring how the medical register might be converted from an administrative convenience into a robust assurance that standards of knowledge and practice are being met.

The working week is NHS time

Where does the profession stand on evaluating the accountability of those involved in the practicalities of delivering high quality service, practicalities that include clinical teamwork, the efficient use of time, and the willingness to respond to strategic managerial leadership? One accountable local strategy, developed to help close the gap between resources and responsibilities, was based on the premise that all of a consultant's time during the working week was NHS time, unless specifically agreed otherwise.[1] Time for non-NHS commitments was viewed partly as an exchange for a real and regular commitment to NHS emergency services at nights and weekends and partly as a consequence of consultants giving up one paid session in changing from a full time (11 session) contract to a maximum part time (10 session) contract. The NHS trust involved in this strategy encouraged consultants to base their private practice on site when possible, to attract income and influential friends to the institution and to enable junior NHS staff to be supported and supervised by consultants throughout the week. The strategy envisaged that for the rest of the week consultants would be available, able to be contacted, and engaged in NHS work in their appointed hospital.

Most of my colleagues do not have the slightest problem with this arrangement: they work a long day, do not count the hours, and are normally at the hospital, except at times that have been agreed for them to be off site. Some, however, do not believe that this arrangement represents their contractual position; their trade union (and mine), the BMA, will support them in this. It is important to analyse the consequences of this view because it could frustrate the prime minister's aim of ensuring that the NHS "delivers exactly what we want" in return for additional resources.

Contractual confusion

Maximum part time consultants (of whom I was one for three years and doubled my income) are expected by the conditions of the standard NHS contract to "devote substantially the whole of their professional time to their NHS work." The term "professional time" is not defined in the contract. Instead, the commitment is expressed in terms of "sessions" defined as "notional half days" of 3 1/2 hours less an allowance for travelling time. Medical directors are aware of some colleagues who, like most of us, work a long day and yet will argue that they can complete their contractual obligations in three days; they then expect time off or additional paid sessions. Sessions are designated as "fixed" or "flexible"; between five and seven sessions a week are fixed. The remainder are considered flexible NHS time for teaching, administration, being available, and for continuing medical or professional education.