The role of the consultant

Transcription

1 The role of the consultant July 2008 CARING FOR THE

2 Introduction The purpose of this paper is to clarify what the CCSC 1 believes to be the role of the consultant 2 in the modern NHS and the characteristics, values and abilities they should possess in order to provide high quality healthcare. The paper addresses these issues in broad terms, and could be used as a basis for more detailed work. A number of the qualities and competencies identified in the paper are reflected not only in the role of the consultant but also in the characteristics of registered medical practitioners across the spectrum of delivery of clinical care. It is envisaged that this paper will promote and feed into a wider BMA vision on the role of the doctor encompassing the views of all branches of practice. It is necessary to define the role of the medically qualified consultant for a number of reasons. First, the role of the consultant will indicate which people should become doctors and the attributes that those who are already consultants should strive to develop. Second, it will shape the grounds on which consultants performance is judged. Third, defining the consultants role and the role of other medically qualified practitioners is important when developing systems of care. 3 In addition, the debate about the role of the doctor is intertwined with many of the current issues affecting consultants, in particular, the possible emergence of a post-cct sub-consultant grade and also the general debate over workforce planning and the perceived erosion of medical professionalism in some areas. CCSC recently launched a campaign to promote focused and planned consultant expansion to meet the needs of patients, training and management. The perceived need for consultants depends on perceptions of what a consultant does. It is therefore important to clarify what is expected of the doctor in all areas of practice within the NHS workforce in order accurately to assess the resource requirements and skill mix needed to deliver care of the highest quality in the future. This is highlighted by the Wanless report, published in 2002, which states that the size and composition of the NHS workforce is one of the most important determinants of the capacity of the health service. 4 The role of the consulta nt 1

3 Background The role of the doctor theme has been brought into focus by Sir John Tooke s final report Aspiring to Excellence. 5 Recommendation 5 of the Tooke report states that: There needs to be a common shared understanding of the roles of all doctors in the contemporary healthcare team that takes due account of public expectations. Given the interdependency of professional constituents of the contemporary multi-professional healthcare team we suggest a similar analysis extends to other healthcare groupings. Clarity of the doctor s role must extend to service contribution of the doctor in training, doctors currently contributing as locums, staff grades and associate specialists, the CCT-holder, the GP and the consultant. Such issues need to be urgently considered by key stakeholders. Notwithstanding the need to keep such a key issue under constant review, stakeholders should seek to reach public consensus before the end of 2008, so important is the issue for current NHS reform. The BMA is seeking to define the role of the doctor issue as highlighted by Sir John Tooke before a conference, scheduled for October 2008, which will address Tooke s recommendations alongside that of the role of the doctor. It is envisaged that the conference will develop a consensus view on the role of the doctor. The results of a YouGov survey of the public will support the consensus statement. One good example of a previous attempt to define the role and value of the medical practitioner was the CanMEDs 6 model. This Canadian project began as a desire to reform medical education to ensure that physicians were prepared for the new healthcare environment following concerns about changes in medical practice. Forces such as patient consumerism, government regulations, financial imperatives, medical information on the internet, litigation and technology were all identified as having a significant impact on medical practice. CanMEDs makes explicit the abilities that are recognised in highly skilled physicians and the framework of core competencies is given below 7 : Professional Manager Communicatior Medical expert and healer Advocate Scholar Collaborator 2 The role of the consultant

4 The role of a consultant CCSC agreed the following as a very broad description of the role of consultants: Primarily as clinicians predominantly involved in the delivery of expert clinical care usually within a team, including the ability to recognise and manage the more complex end of the specialty spectrum (diagnosis, management decisions, difficult cases, including apparently simple cases which have a high incidence of complications in more inexperienced hands) but also involved in running departments, managerial decisions, teaching, training, researching, developing local services generally being involved in the wider management and leadership of the organisations they work in, and the NHS generally. This describes how most consultants work now and it describes what the 2003 contract was intended (by BMA negotiators at least) to remunerate and develop (a consultant-based service). This definition includes the core values identified at a BMA seminar for local consultant representatives on 8 April 2008 where the role of the doctor was the key theme. These were: clinical expertise; managerial skills to lead healthcare; leaders of quality and innovation in new treatments; and the training provision for the next generation. The CCSC description of the role of a consultant is also underlined by the BMA s Patient Liaison Group which believes that the role of the consultant is to: Demonstrate the competence and experience to cover complex cases e.g. more than one disease in a patient. Train and mentor junior doctors. Accept ultimate responsibility for the care of all the patients referred to them (in any way) under their care, even if their treatment is being carried out by other doctors within the consultant s team. Provide definitive medical opinion/treatment on a patient that cannot be managed in primary care by their GP. This statement emphasises the importance of the clinical expertise of consultants and the value placed on this by patients. It is clear that when defining the role of the consultant, one size does not fit all. Different specialties need different attributes. It is important that all doctors do not have the same role, and it is impossible for them to all to practise everything in the role description to the same level all the time. This is because diversity is crucial to development and innovation, and bringing different points of view to bear on the problems presented by patients. Consultants are often marked out by a mixture of abilities: clinical skills involve taking on the most complex cases; management aspects involve the development of a service and the leadership of it; training provision requires the dissemination of professional knowledge and expertise to others....despite obstacles, the vast progress that the NHS has made in the half century since it was founded has largely depended on reforms led by clinicians, that have require ingenuity, vision, insight, negotiating skills and often a willingness to be personally exposed to risk. 8 The role of the consulta nt 3

5 With reference to the CanMEDs model, the various strands will vary in importance from one consultant to another. Although a wide variety of activities make up a portfolio of what a consultant does, the specific activities undertaken by consultants will vary depending on the individual s job plan. In addition, consultants careers develop over time for example with a varying proportion of work being undertaken in research, teaching or management. The clinicians of tomorrow will have differing career pathways with some taking on increased teaching and training and others moving to increased or decreased participation in certain areas of work, for example, emergency care. Employers and consultants need to work in partnership to optimise the development of their key personnel to ensure the most effective patient care. Many factors have changed the working patterns of consultants in recent years; an increase in designated teaching time for junior doctors, increased patient throughput, increased workloads due to a reduction in junior doctors hours, and pressures for consultants to be more accountable for the work they undertake. In addition, as the demography of the medical workforce changes with an increasing proportion of CCT holders, it is likely that consultants may deliver even more of the service than is currently the case. Clinical excellence and expertise Both the CanMEDS model and the CCSC statement on the role of the consultant highlight clinical expertise as the primary feature of a highly-skilled physician/consultant. This central role as a medical expert must be interconnected with the other competencies described such as the ability to communicate, manage, innovate, educate and train. As medical experts, consultants integrate all of these roles in their provision of patient-centred care. This ability to combine wide-ranging responsibilities, expertise and complex knowledge-base enables consultants to provide the highest quality of care to their patients. As medical professionals, consultants have a responsibility for the integrity of the knowledge base, for its proper application, for its expansion and for its transmission to future practitioners and the public. 9 The primary objective of a consultant is to use expert knowledge and skill to diagnose and treat patients while retaining ultimate clinical responsibility for their care. It is a responsibility of the consultant to practise according to the evidence base, guided by experience and compassion. Where the evidence is not to hand, the consultant is responsible for searching it out and evaluating it for scientific validity and practical application. Where the evidence does not exist, the consultant understands the importance of the lack of an adequate evidence base and is able to undertake research in order to extend the evidence base. These three requirements evaluating, discovering and extending are what require a doctor to be educated to a higher level and for a longer period than most other healthcare workers. The caveats are that: While not every doctor operates a scientific enquiry as a research programme, all doctors must at all times work in a spirit of scientific enquiry; Many questions are not reducible to the extent that they can be answered unambiguously with the current state of scientific technology; 4 The role of the consultant

6 In Hippocratic Oaths, Raymond Tallis considers evidence-based medicine and expresses the remaining need for doctoring: medical decision-making can never be automated. All patients are different and it is sometimes necessary to depart from conventional practice. The recent emphasis on narrative-based medicine, taking account of individual characteristics of patients, is a healthy corrective to the notion that medical practice can be reduced to a series of algorithms. While evidence-based medicine is a necessary condition of good medical practice, it is not a sufficient condition. The evidence and the guidelines and protocols that are based upon it do not take the doctor all the way to the decision in the individual case. There is room for judgment, for application of common sense, and for modifying practice in the light of the patient s priorities. Those who depart from the guidance, however, should do so in full knowledge of the guidelines and document the reasons for deviating from recommended practice. 10 Doctors, including consultants, will ordinarily work within established treatment methods. However, there are occasions where consultants use their judgement and expertise to work outside protocols where the needs of their patients require that they do so. Working outside the protocol may also encourage the development of new treatments and the evolution of medicine. According to the GMC s Good Medical Practice doctors must: Make the care of your patient your first concern and; Protect and promote the health of patients and the public. 11 In order to fulfil these duties a consultant must use their professional and educated judgement to balance the needs of the patient in front of them with those of a wider group, at the same time being accountable for their professional practice and prepared to justify their decisions and actions. 12 The need to take into account a variety of considerations when treating a patient is neatly summarised by Dr Harvey Cushing, an eminent American neurosurgeon: A physician is obligated to consider more than a diseased organ, more even than the whole man - he must view the man in his world. In the Journal of Applied Philosophy, John K Davies considers a professional s duty is not primarily to please but to do or to advise the right thing. 13 The integrity of the doctor and what gives him or her professional status is the willingness and ability to make difficult decisions about a course of treatment because he or she knows that this is the best advice, informed by up to date knowledge, opinion and ability. Delivery of the best healthcare does not only depend on accurate diagnosis and treatment; effective communication between the consultant and the patient is essential too. Consultants need to be able to communicate clearly with patients to allow them to make informed choices about their treatment. In some situations, patients prefer the doctor to act on their behalf as they are confused by being faced with important decisions at a time when they may already be understandably anxious. The role of the consulta nt 5

7 As identified by the CanMEDS model, consultants act as the patient advocate, and help them navigate the healthcare system, using their expertise and influence to promote and advance their health and well being. As patient advocates, consultants identify and address factors which determine patients health; this can involve attempts to change specific practices on behalf of their patients. Advocacy also includes the provision of guidance and support through what can be complex care pathways. Patients rely on their consultants for this reassurance at times when they may feel apprehensive or confused. As patients differ in personality and approach, consultants need to develop the necessary skill to identify these differences and adapt their consulting manner accordingly. Trust is a vital component in the doctor-patient relationship. Patients like things done right first time in an assured manner by an experienced professional who gains their confidence and trust. As Dame Janet Smith stated in February 2005: I think the public ought not to even have to think about whether they trust their doctors it should be something that they are able to take completely for granted. 14 The behaviours that strengthen trust are easily recognisable. According to the Royal College of Physicians report on medical professionalism these behaviours include courtesy, kindness, understanding, humility, honesty, and confidentiality. 15 Failure to demonstrate these behaviours will undermine trust. They are essential to being a good consultant and echo the duties of a doctor as described by the GMC. 16 Consultants must have an ongoing commitment to the continuous improvement of their practice through continuous professional development. They must be able to demonstrate a commitment to inquire into and review the clinical outcomes of their work and to have those audits scrutinised by their peers. Managerial skills and leadership Consultants are the key players in NHS clinical teams and are needed to manage and lead the service. They are essential to the success of the NHS and are required for service innovation and development, including clinical research. Consultants play an important role in setting priorities, developing policies and making other management decisions within their own departments and hospitals. By virtue of their longevity in post and their understanding of the day to day core business, both as leaders of individual services and in the wider context of hospital management, consultants are key to continuity in hospitals. The leadership of clinical teams is an important part of many consultants roles. The GMC states that when working in a team, consultants should act as a positive role model and try to motivate and inspire colleagues. 17 Consultants are responsible for review and audit of the standards of their team and should take steps to correct any deficiencies. The extensive training, knowledge and experience of consultants, means that they are well placed to manage unpredictable situations and balance and manage the risks associated with making leadership decisions. 6 The role of the consultant

8 Consultants must be able to work in partnership with the wider healthcare team and be responsible for the allocation of duties within the team. As leaders, consultants are responsible for developing protocols for members of the clinical team. Consultants are also involved in determining the level of competency required by staff who undertake delegated medical procedures, and in training other health care professionals. Consultants must also develop the skill of working effectively in partnership with others, because at times they will be members of a team led by others, often another consultant. They need to work collectively with others, particularly NHS managers, to best manage resources and balance the needs of the individual patient as well as the wider population. At a higher organisational level there is increasing emphasis placed on engagement of doctors in the management and leadership of health services. 18 Recognising the added value that doctors can bring to management of the NHS, its Chief Executive, David Nicholson, has called for the shortlist for every trust Chief Executive post to have a clinician on it within three to five years. 19 Evidence from both Audit Commission and Commission for Health Improvement reports have demonstrated that the most effective and efficient NHS organisations are those with the highest levels of clinical engagement and leadership. 20, 21 The importance of engagement between clinicians and finance professionals was also emphasised in 2007 by the House of Commons Select Committee on Public Accounts. 22 Medical leadership at a higher management and organisational level ensures that there is a focus on providing high quality and up to date services as means to improving the quality of healthcare. Leading change and innovation As well as leadership of services and health care professionals, consultants provide leadership and innovation to pioneer and drive forward new treatments and models of care for patients. Studies have illustrated that consultants lead changes in practice to encourage new ways of working for both doctors and nurses which address local needs and improve patient care. In December 2001, the BMA published the report Pioneers in patient care: consultants leading change. 25 This report provides a series of 80 case studies highlighting the key role played by consultants in pioneering improvements in patient care. The report profiles 81 consultants from a range of hospital and community specialities all over the UK, and regions covered include London, Midlands, North East, North West, Northern Ireland, Scotland, South East, South West and Wales. The NHS needs consultants as innovators of change and to introduce new forms of medical care in order to drive medicine forward. This is essential if NHS services are to be driven by a cycle of continuous quality and improvement as identified as a core principal in the NHS Plan. 26 The role of the consulta nt 7

9 Training the next generation The BMA seminar for local consultant representatives in April 2008 recognised the importance of disseminating expertise to the next generation. Consultants play an indispensable role as educators and possess the range of skills that doctors in training need to acquire. As senior medical staff, consultants provide the greater part of the education and training for junior doctors as well as aiding the development of their specialty doctor colleagues. Medical training is not simply a list of different skills, it must include consideration of the interaction of those skills, with weighting given to them relevant to circumstance, experience and the ability to deal with uncertainty. The role consultants play in teaching and training has been identified by the GMC as a key attribute 27 and was formalised by the publication of The Doctor as Teacher which outlines the educational obligations and professional and personal attributes of the doctor with responsibilities for clinical training and educational supervision. 28 In The Doctor as Teacher the GMC states that all doctors have a professional obligation to contribute to the education and training of others, and that every doctor should be prepared to oversee the work of less experienced colleagues. This clearly expresses obligations for the experienced consultant in relation to the less experienced junior colleague or associated healthcare professional. This is also crucial if patients are to receive the highest standard of care possible. Patient care must be adequately supervised by an appropriately experienced clinician and those who will become consultants of the future must learn to provide a high standard of care from observation of their seniors. This is the role fulfilled by consultants who take on the responsibility as clinical supervisors. Research has shown the impact of consultant supervision on outpatient follow-up rates as junior doctors are less likely to make follow-up appointments when directly supervised by their consultants. 29 As well as clinical supervision trainees will also need someone to help then understand what they have learnt from clinical experience and integrate this with what is learnt from formal educational activities. 30 This is the role of the consultant as an educational supervisor. An educational supervisor is defined as someone who can help trainees understand how they learn so that they can make best use of the educational opportunities available; someone to assess their progress and provide feedback; and someone to help them overcome difficulties. 31 A number of consultants are also involved in the planning and quality assurance of training at a national level through their work with the Royal Colleges, deaneries, PMETB and other relevant bodies. Here consultants show both their roles as leaders and as teachers, essential for the future development of both medical specialities, doctors themselves and of course improving patient care. Consultants use their positions within the Royal Colleges, PMETB and other bodies as ways of promoting quality and professional standards in post graduate medical education. These positions are also used to influence the development of policies designed to maintain and enhance the high quality of care consultants are able to offer to patients. This work involves conducting research and issuing guidance and the general advancement of high standards. 8 The role of the consultant

10 Summary of key points A consultant: Provides high-level specialist clinical input for patients in their care, including carrying out complex procedures, and managing complex cases. A consultant is expected to be able to practise independently and autonomously, with competence in managing the vast majority of scenarios that could occur in their specialty. Has ultimate responsibility for patients under their care, including where care is delivered as part of a patients pathway through multidisciplinary care. Offers a specialist opinion for other teams on an area of sub-specialisation or personal academic interest. Acts as an influential patient advocate within the healthcare system. Provides leadership to multiple team areas of trust activity. Quality assures their practice and that of the teams they lead through clinical audit, appraisal and revalidation. Provides, leads and oversees training and education for junior doctors, medical students and perhaps other healthcare professionals at both local and national levels. Devises, reviews and revises organisations policies objectives, rules, working practices and protocols. Conducts medical research in the public sector and/or private sector. Promotes new practices and lead innovation in new models of care for patients, new forms of treatments and use of new technologies. Practises medical management (determining departmental structure, devising local protocols, service development, implementing national guidelines and research findings, junior and peer appointments, etc.) The role of the consulta nt 9

11 References 1 The Central Consultants and Specialists Committee is a Standing Committee of the BMA, established by the Association s Council and Representative Body. It represents all senior hospital medical staff, irrespective of BMA membership, and has delegated authority to negotiate terms and conditions of service for those it represents. 2 As defined by those who are CCT-holders on the specialist register appointed by an AAC to a NHS consultant post or the equivalent in the independent sector. 3 The role of the doctor, BMJ article, 17 November Securing our Future Health: Taking a Long-Term View, Final Report. Derek Wanless. April Aspiring to Excellence: Final Report of the Independent Inquiry into Modernising Medical Careers led by Sir John Tooke, Recommendation 5. 6 CanMEDs is a project set up in Canada in the 1990s to ensure that specialty training is fit to meet societal needs. 7 It should be noted that the CanMEDS model as used in this paper applies to consultant working in the NHS in the UK rather than those working within the model in Canada. 8 R. Tallis, Hippocratic Oaths: Medicine and its Discontents, (2004) 83 9 Cruess, S R., Cruess, R l., Medical Professionalism in the New Millenium: A Physician Charter Americal Board of Internal Medicine 2002; 136: R. Tallis, Hippocratic Oaths: Medicine and its Discontents, (2004). 11 General Medical Council Good Medical Practice General Medical Council Good Medical Practice John K. Davies (1991) Professions, Trades and the Obligation to Inform Journal of Applied Philosophy 8 (2), Doctors in Society: Medical Professionalism in a changing world, Royal College of Physicians, Report of a Working Party Doctors in Society: Medical Professionalism in a changing world, Royal College of Physicians, Report of a Working Party General Medical Council Good Medical Practice General Medical Council Good Medical Practice The Enhancing Engagement in Medical Leadership project is a joint project led by the Academy of Medical Royal Colleges and the NHS Institute. The project goal is to create a culture of greater medical engagement in management and leadership with all doctors at every level. 19 The rise of the doctor-manager, BMJ 2007;335: Audit Commission A prescription for partnership: Engaging clinicians in financial management Commission for Health Improvement, Lessons from CHI Investigation House of Commons, Select Committee on Public Accounts, Seventeenth Report, Psychiatric Bulletin (2005) 29: British Medical Association, Pioneers in patient care: consultants leading change DH_ General Medical Council Good Medical Practice General Medical Council, The doctor as teacher Lo S, Fergie N, Walker C, Narula A (2004): What is the impact of consultant supervision on outpatient follow-up rate? Clinical Otolaryngology and Allied Sciences 29 (2): Johnson N, (2001): Training of junior doctors: the responsibility of consultants and trainers Postgraduate Medical Journal 77: General Medical Council, The new doctor The role of the consulta nt 11