Compound fractures

January 20, 1995

Student funding for university hospitals is under review. Peter Richards welcomes some of the changes, but asks if the academic backbone of clinical education is near breaking point.

The NHS "Reforms", Britain's brand of the international health care revolution, were billed as good news for medical education. Indeed, one senior manager described the Government's 1989 White Paper Working for Patients as "the dean's charter" because, for the first time, the Service Increment for Teaching and Research (SIFTR) was to be targeted on the hospital facilities the medical schools needed.

SIFTR is a very substantial sum. It is designed to offset the increased NHS costs of university hospitals acting as the backdrop to undergraduate medical education and as the hub of clinical research. With a price of Pounds 40,000 a year on each head (including the R element attributable to the environment of research, in which all medical students learn), clinical students have become hot property to hungry hospital managers. Indeed, SIFTR accounts for about 10 per cent of the total income of the larger university hospital NHS trusts. Targeting of this resource with respect to teaching is acquiring teeth through annually reviewed educational contracts between medical school and trust within a strategy agreed between regional health authority (RHA) and the dean of the medical school.

Here were two steps in the right direction. First, application of resources to the point of educational activity in all hospitals with a substantial teaching commitment. Second, an invitation to control through contract the quality of learning opportunity in a way most clinical teachers, many of whom are NHS consultants, would formerly have found unacceptable.

But the SIFTR functions largely as a general subsidy to the shaky economy of teaching hospitals. Pull out this mainstay of their economy too fast, even with the desirable intention of re-injecting it according to academic priorities, and the system may collapse.

By accident rather than by design, the hard-won academic backbone of clinical education is seriously threatened. Medical education has moved on a long way since Flexner in 1911 described clinical education in London as "an incident in the life of a busy consultant . . . (who) lacks the time, even if he has the training, which will enable him to bring to bear on clinical problems the artillery which the chemist and the pathologist are forging". We are in danger of putting the clock back.

The coming of age of academic medicine has been slow, painful and, until recently, unenthusiastically witnessed by both its parents - the universities and the medical profession. Medicine was long regarded as academically soft and demeaningly technological by universities. The profession, on the other hand, considered that registrable qualifications to practice were largely its prerogative.

There was a battle royal in the 1830s, for example, over whether the new medical degree of the University of London should be a licence to practise. As recently as 1944 an eminent surgeon assured the principal of the University of London that the London teaching hospitals were world-famous and the Royal colleges held examinations which led to licences to practise. So where, he asked, did the university come into the picture?

What then is the threat to medical education? An effective medical school is an amalgam of scientists, clinicians, clinician scientists and professions supplementary to medicine; a consortium of complementary, innovative, mutually inspiring skills and interests. The staff need to pursue a suitably specialised spectrum of clinical practice at the frontiers of knowledge both for their professional fulfilment and their research.

They also require an appropriately wide range of patients to meet the education needs of students and for research into common conditions. Principal university hospitals have successfully balanced their clinical practice by attracting patients from near and far in a way no longer feasible in a system where patients follow contracts and contracts, by and large, are awarded to the local and lowest bidder. Most main university hospitals are in city centres because that is where their universities are. It is not of course where operational costs are lowest, nor is it any longer the place where so many people live.

There is no justification for preserving hospitals which are not needed. Practically all major university hospitals are, however, still needed by their local population and by patients from further afield to whom they can offer specialised skills that a small hospital cannot satisfactorily sustain: small is in this respect not beautiful but second rate.

It is not simply a matter of keeping skills sharp. The improvement of specialist techniques and the advancement of knowledge require wide experience of a narrow field and a multidisciplinary team which only a large centre can sustain.

If highly specialised health care is farmed out to a nation of small health-shopkeepers, patients and postgraduate medical education will suffer because academic involvement will be lost from specialist centres and with it much of the clinical research in which the United Kingdom, through its NHS base, has come to excel.

University hospitals are not running out of work but much of their effort distorts the desirable balance of experience for broad education and threatens the specialist services. As neighbouring hospitals close and non-emergencies are diverted by contracts elsewhere, the inner city university hospitals are left with the medico-social fall-out from the deprived, the elderly living alone, and the psychiatrically disturbed.

Theirs are important needs, but it is not sensible that they should overwhelm the diminishing resources of university hospitals and displace, cuckoo-like, their wider educational, research and specialist services. When the contract for acute emergency admissions has been fulfilled, no institution with a conscience can send away from its doorstep the seriously ill, the moderately ill but homeless, and the deeply disturbed.

Public hospitals (and the UK universities have always used their expertise and resources in the support of public medical services) are rightly expected to justify their existence and their cost, but the degree of pressure is fast becoming incompatible with first-class education and research: incompatible even with first-class service. The rapid transit of all patients through hospital is making it difficult for students to get a look in and almost impossible for them to acquire a sense of continuity of a patient's illness.

What's new? A senior civil servant (H.C. Burdett) remarked 101 years ago that "the object of the hospitals is to cure with the smallest number of beds the greatest number of patients in the quickest possible time."

Carefully structured teaching clinics (which inevitably increase costs because relatively few patients are seen), and well organised teaching around day investigation and intervention, can overcome part of the students' problem. Students learn from patients. The art of medicine is no more learned from lectures or books than driving from The Highway Code or a car manual.

To experience a more representative balance of illness, students will need to spend more time in peripheral hospitals. Even here the pressure for short stays is such that learning will be more from snapshots than from observing the natural history of disease.

Continuity of an illness and its human context are best achieved in the patient's home and as the epicentre of health care moves from hospital to community, students will need to move with it.

The purpose will not be to extend undergraduate training in general practice but to develop specific clinical skills and to acquire what The Lancet of 1892 called "the health bearings of the civilisation in the midst of which we are living".

Suitable teachers should not be difficult to find: general practice has after all taken its postgraduate educational role much more seriously than most other specialties and the skills should be transferable given clear aims and objectives. The biggest problem will be the cost of their time.

Acceleration of the historical pressures on inner-city university hospitals is only part of the problem. A series of unrelated and in themselves commendable changes in conditions of work, manpower, the preregistration year, specialist training and continuing medical education have had a cascade of unintended and unforeseen consequences for medical education and research.

Even the recent and well-intentioned Culyer report has a sting in its tail for universities. In wishing to target the "R" element of SIFTR on the institutions where the research service overheads fall, Culyer may have underestimated the serious consequences of any net movement of the "R" from university hospitals.

A recent independent enquiry found that even the current level of SIFTR undershoots real costs. Culyer also fails to say whether the "R" proportion of SIFTR should be considered to be the 2 per cent increment for which additional funding was provided when the "R" was added in to SIFT a few years ago or the notional 25 per cent which is often assumed, or something between the two? Can the universities be assured that they will be consulted? Will they participate in the reallocation of the "R" back to university hospitals, for fixed research infrastructure costs and for research volume-related service costs?

Falling recruitment of academic clinicians is another problem. It will fall further if the salary link between whole-time NHS consultants and clinical academics with honorary NHS contracts is broken, either because of introduction of "performance-related pay" to the NHS or because the universities are unwilling or unable to honour a series of unfunded medical salary increases.

First-class recruits are already in short supply and would not come cheap; universities would have to pay up or pull out of medicine.

The political revolution in health care, by its obsession with financial and managerial process, not only threatens academic medicine but jeopardises the soul of medical professionalism worldwide. "Health services are not", said Sir Douglas Black, former chief scientist at the Department of Health and, later, president of the Royal College of Physicians of London, "for the welfare and aggrandisement of those who work in them: are not for the profit of native or foreign entrepreneurs; are not even for the advancement of medical science . . . No, health services are first and foremost for the good of patients - even perhaps more than for the public health, and that is the touchstone by which they must be judged."

That also is the touchstone by which students, doctors and even managers should be educated. There is no reason for universities to apologise for being concerned to ensure that the health care revolution, good or not for patients and society today, does not inadvertently prevent medical education and research from securing the good of both patients and society tomorrow. Indeed, we should be failing in our public duty if we did not voice our concern.

Peter Richards is chairman of the Council of Deans of Medical Schools, chairman of the education committee of the Royal College of Physicians of London and dean of St Mary's Hospital Medical School, Imperial College.

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