> Difficult to see how a unit for example like Ray's can close
> at night when there are no other local units to provide the
> cover. I suppose in some areas it may get left to nurses to
> signpost to specialities assuming they have enough staff to
> comply with reform of the SHO grade and EWTD.

Covering the hospital at night is going to become a major issue for other
specialities. They'll lose their SHOs and probably registrars. Clerking will
largely cease to be done by doctors (which is no bad thing from either the
training or service viewpoint). So a lot of the 'signposting' is likely to
involve initiation of a pathway (I'm no great friend of pathways in general,
but there are a lot of patients admitted who clearly require sending to an
assessment unit; don't need immediate intervention; need a few tests that
fit well into protocols; and can wait for the next scheduled consultant
review time- provided the tests are available by then. These patients don't
need a doctor during the hours of darkness)

> If I may add - it's the government that is driving the agenda
> on this - not
> the educationalists. As consultants, we will each have a role
> in ensuring
> the govt's quantitative approach to the issue does not
> compromise (further
> than it already has) the qualitative aspects of training and service
> provision.

It is however, the educationalists who are moving towards making the
foundation year doctors (and possibly ultimately all doctors in training)
have no service commitment at nights (possibly work where this is needed for
training purposes, but in this case likely to be supernumerary). To give the
educationalists their due, they are educationalists with a remit to look at
education, not service commitment. The first time I recall a pronouncement
that we'd best start looking at ways of running our hospitals without SHOs
because they were going to be supernumerary soon was 1992.

Interesting situation coming- no trainees after midnight, proposal that
staff grades automatically be allowed to progress to higher specialist
training (meaning that staff grade numbers will be those who choose that
career path rather than that of the consultant instead of including some who
wanted to become consultants but were unable to secure HST rotations); new
consultants' contract makes residence after 7 pm voluntary. I think we need
to look at some pretty radical solutions- not just the new ways of working
with other professions acting autonomously, but with making better use of
our autonomous professionals including doctors (for example, when clearing
minors, more time is spent doing paperwork than talking to or examining
patients- addressing this issue could reduce the service commitment needed)

> Could have told you that last year, Ray.  With the Foundation
> Year SHO, EWTD's, new GP contract it doesn't bode well for
> A&E.  As I have said countless times that it is unsustainable
> and 30% of A&E departments may have to close or restrict
> their opening.

I don't think that will necessarily be all that workable. Cover after
midnight still can't be provided in a restricted number of departments. SHOs
won't provide it at all; staff grades may move to departments with
restricted hours; consultants may choose not to provide it after their next
job plan review.  Maybe cover with SpRs, but likely to be the case that they
will require consultant supervision. Basically only workable with either a
consultants' contract that makes compulsory resident on call possible or a
change to remuneration for unsocial hours.

New GP contract focuses the mind. For the last decade or so, it has been
fashionable to say that there's no such thing as an inappropriate attendance
at A and E and that an emergency is whatever the patient think be an
emergency. However, it will soon be impossible to provide an adequate
service to those patients whose conditions will deteriorate significantly if
not treated within hours while still providing a 24/ 7 full service to all
those who attend. Triage must be readdressed with a view to sending many
patients to a more appropriate level and type of service.

Matt Dunn
Warwick


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