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Commentary from Westminster

Consultant Numbers, AgainANYONE seeking change for the better in the NHS would

do well to study the fate of plans, laid in 1981, to increaseNHS consultant numbers and reduce junior hospital posts.The Government, health authorities, all doctors’

representatives, and the all-party House of CommonsCommittee on Social Services agreed on targets of 1

consultant to each junior doctor by 1988 and 1’ 8 consultantsfor each junior by 1996. However, as the Social ServicesCommittee points out in its latest report, nothingapproaching this has happened. The DHSS is accused ofhardly trying even to find out why so little progress has beenmade towards a health service in which most hospital patientswould be treated by consultants ("fully trained doctors", inthe phrase of the committee). Pilot projects to identifyreasons for the lack of progress and solutions have not been

encouraged by the DHSS, the committee was told by theNational Association of Health Authorities. The DHSS saysthat health districts "are not anxious to have the spotlightturned on them and be made a pilot project". Whatever thetruth of this side-issue, the central fact is that the consultant tojunior ratio has barely changed since the targets were agreed,and shows little sign of early improvement.The NAHA told the committee that such progress as could

be identified was neither steady nor sustained. The HospitalJunior Staff Committee reported that progress was

negligible; the President of the Royal College of Surgeonscalled it lamentable; and even the Minister of Health, MrKenneth Clarke, confessed to disappointment. The reportidentifies several reasons for the "chasm between intentionand performance". While decisions on staffing are taken atregional and district level, there is little pressure on themfrom above to take any initiatives, says the committee. In theshort term at least the plan would be expensive. While thecommittee has urged that some growth money to authoritiesshould be earmarked for consultant expansion, theGovernment insists that the money must be found from theauthorities’ efficiency savings.Regional strategic plans which the authorities now have to

submit to the DHSS should include programmes for

increasing consultant numbers, says the report. But theCommittee acknowledge the cash pressures these must

generate, quoting the North East Thames region’s complaintthat consultant expansion will be one of the region’s "greatestchallenges" if acceptable standards of patient care are still tobe afforded. At its present rate of progress North EastThames should achieve 1’ 5 juniors to each consultant by1993, a long way short of the Government target but betterthan most other regions. It is time for the newly installedNHS Management Board to issue to regions unambiguousguidance on how they are to reach consultant/junior targets,the Select Committee’s report urges.Some consultants have proved hard to reconcile to the

scheme as a whole, the report says, though the extent ofconsultant resistance is sometimes exaggerated. Consultantsfavour more consultant posts, but are not keen on the extrawork-load they will face if junior posts are reduced. "We havebeen made well aware of the consultants’ unwillingness totake on further or more onerous on-call responsibilities; toreduce the tiers of on-call cover; to go much further down theroad of cross-cover ; and to move towards consultants sleeping

in," says the report. Yet many consultants are on call as it is,and many-not only those in laboratory specialties-workvirtually unsupported by junior staff, the committee notes.While consultants’ leaders support change, individualsremain suspicious, and even if they support the principle"there is no incentive for a consulant to seek change athospital level". Thus reduction of junior posts has notaccompanied such minimal consultant expansion as has takenplace. In many areas, especially psychiatry, reduction ofjunior jobs would not be expected to bring sufficientconsultant expansion to meet service needs.The report rejects once again the creation of a "sub-

consultant" grade. "It is clear there is still no great desireamong consultants for changing the basis of the medicalcareer structure. While what a consultant is expected to domay change, there is in our view no good reason to invent newgrades to conceal the difficulties."The Minister of Health and the DHSS still say they favour

consultant expansion, says the report, but warns they are"unlikely to do anything if left to their own devices". But inthe final analysis, the Committee insists, it is the Governmentwhich is proposing a consultant-based health service, "and itis to the Minister we are entitled to look for operational plansto bring those changes about". The Government’srestrictions on the immigration of foreign-trained doctors andon training posts in the NHS for them will make littledifference in reality. The restrictions "do not appear ofthemselves to prevent an overseas graduate gaining entryclearance on the basis of acceptance into a training post everybit as limited as at present. Indeed, the expectation is thatthere will be a steady inflow of doctors for such posts". Nowis the time to thrash out a proper sponsored training scheme,so that a halt can be called to the exploitation of foreigndoctors in the NHS as pairs of hands in unpopular specialties.Progress in consultant expansion also requires an improveddata system for the NHS as a whole. "Given the time, energyand money devoted to manpower data and computer reportsover the last few years, it would be disgraceful if we did notemerge with a compatible national system", says the report.

Limited ListNow that general practitioners have declared they will have

no truck with a local system of appeals against the exclusion ofdrugs from the Government’s limited list, the Government ishappy to do nothing at all. Health Ministers have no

obligation to operating the limited list with no appeals systembuilt into it, other than the regular review of the list to takeaccount of technical advance. To this extent, the BMA seemsto have made a serious strategic error in its opposition even toless-than-satisfactory appeals procedures, on the grounds thatsuch procedures legitimise the concept of the limited list.But backbench MPs-under pressure as much from drug

companies as from doctors in their constituencies-are nowbeginning to demand at least some sort of appealsmechanism. Questions on the subject are beginning to appearon the Commons’ order paper. One Tory, Mr MichaelLatham, insists he only supported the limited list plan in thefirst place because he was led to believe it would include anappeals system. He regards the BMA’s stance on the matterwith horror, and says he is convinced that a genuine localappeals system is vital to the interests of patients. Hepromises to make a nuisance of himself until Ministers seethings his way.

RODNEY DEITCH