> The New Consultant contract is rejected, and at some point a
> new-and-improved Contract is agreed (or enforced by the Gov).
> GP's will increasingly pull out of out of hours work.
> SHO training is drastically improved, by removing the service
> element of their jobs as they pass through the two year
> General Training (European Working Time Directive making sure
> they don't stay up past bedtime.) The gap between this and
> SpR post is as yet clear, but is likely to be some version of
> a speciality training.

With you so far. We've been told for over 10 years now to consider how we
would run our departments without trainees.

> SpR Training will drop to three years and most of that
> centralised in order to improve its quality (and conform with
> the EWTD.)

Not sure that centralisation will happen- in most specialities (apart from
the Medical specialities) there is more emphasis on spending periods in DGHs
as part of training. It is possible that after the 3 years (or whatever) a
couple of years subspecialist training will be confined to certain
hospitals, but this will not benefit these hospitals in terms of general
service input. SpRs will become increasing irrelevant in any case- like SHOs
it is likely that more emphasis will be placed on training at the cost of
service commitment. You will be unable to justify SpRs spending a large
proportion of their time seeing minor injuries and minor medical problems.
If we say that sprained ankles are no more important or complex than
multiple trauma or septic shock, then SpRs should be seeing broadly equal
numbers of each. I'm not saying this is a bad thing, just it is likely to
happen. Also SpR numbers are currently high relative to numbers of
consultants. In a steady state, if you spend 4 years as a SpR (taking out
time on secondments) and on average 28 years as a consultant (early
retirement being clamped down on), then you need 7 consultants per SpR, so
can need 35 consultants to support 24/7 SpR cover in one department.

> Perpheral DGH's will rely on NCCG cover for service. There is
> a shortage of Doctors willing to do this work at present, so
> many units will be short staffed.
> Central, teaching hospitals will be relatively well staffed
> as they will have SpR's and NCCG staff, while DGH's will
> struggle to find staff.
>
> The result? DGH consultants will be required to do the work,
> a large amount of it out of hours. Of course there will be
> less of it, as we will have MAU and other speciality
> admission units that will cream off the Acute stuff

Been tried. Medical consultants won't take this on (especially as they will
not have the juniors)

> and MIU's
> for the minor stuff. This leaves us with the social problems
> and less glamourous stuff, in addition to an increasing
> amount of out of hours GP workload.

Social problems can't be sorted out out of hours- there isn't the support. A
more likely scenario is taking the DHs streaming document to its conclusion.
Take minor injuries, minor medical problems etc out of A and E- triage,
initial management by NPs or physicians assistants. recruitment difficult at
the moment as nurses are mainly university graduates now and graduate
unemployment is low, but in a recession nurse recruitment gets easier.
>
> I accept this is a rather extreme view, but I think we have
> an interesting 10 to 15 years ahead of us.
>

We do. My scenario however is a little different. Trainees and NCCGs are at
best a medium term solution (as we agree). This applies to all sizes of
hospital, not just DGHs. In the long term most service will be provided
either by non medical staff or by A and E consultants. Non medical staff are
cheaper for treating minor injuries/ minor medical problems; social problems
are best sorted out by people with community sessions (GPs spring to mind)
so ultimately A and E consultants will have to justify their existence if
the speciality is to survive. This could be done by taking on more
'observation medicine' but more and more protocols are being developed to do
this with decreasing medical input in terms of time. The only way forwards
is down the acute medicine route. This is wide open to us at the moment.

Matt Dunn
Warwick


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