James L. Bowen says that to halt the damaging effects of NHS changes, one body is needed to bring together medical teaching, practice and research
Recent correspondence, stimulated by the report of the independent task force headed by Sir Rex Richards on clinical academic careers, has drawn attention to a proposal in that report that has been current for some time -that serious thought be given to the concept of establishing one type of organisation, such as University Hospital NHS Trusts, that would be responsible for training doctors, conducting medical research and delivering clinical care. This proposal needs careful consideration, but why has it been made?
For many, "teaching hospital" implies a centre of excellence in which the best clinical service is provided and doctors are trained. This is not an unreasonable assumption. But what is not generally realised is that such institutions are no longer the united places that they used to be. Gone are the days when there was close dialogue between the governors of the hospital and the councillors of the associated medical school.
The introduction of the internal market in the National Health Service and the arrival of accountants to take the places of the hospital secretary and matron put an end to the "knock-for-knock" arrangements whereby the medical school and hospital assisted each other with clinical care and teaching. Both institutions have had to spend considerable time, effort and money determining which is responsible for what, a largely paper-driven exercise that has obscured the primary objectives to the detriment of patients and students.
The government's recent white paper on the health service contains proposals that the internal market is to be abolished. That is good news, though it seems that one bureaucratic system will be replaced by another. But it is greatly to be regretted that there seems to be no effort being made to stem the crisis that is developing rapidly in medical education and research. For as long as hospitals and medical schools remain separate organisations, there can be little hope of the former close working relationship being restored.
The fact remains that the two are dependent upon each other. The hospital needs the school to provide a large part of the clinical service to its patients and the research upon which improvements to that service are based. The school needs the hospital for the provision of and access to clinical material on which to teach and carry out research.
This places the clinical academic staff of the medical school in the unenviable position of being accountable to two masters -the medical school, through the head of the academic department, and the hospital authorities, through the clinical head of service. Being primarily doctors,it is understandable that their first responsibility is to patients, but it is on their research output (and teaching, regrettably to a lesser degree) that they and their institution are judged and rewarded. Because of the reduction in a hospital's staffing, associated medical school staff are having to undertake more and more clinical work at the cost of time spent on the academic duties for which they were primarily employed.
The employment of clinical academic staff and their relationship with the hospitals to which their medical school is associated are matters that need reviewing. The clinical academic whose main employer is the university/ medical school has always needed access to hospital patients and facilities. In the past, such access was achieved via formal recognition by the granting of honorary titles, eg honorary consultant, honorary senior registrar, etc. In return, a medical school would recognise the teaching contribution made by hospital staff by granting them an honorary clinical senior lectureship or professorship. In this way,they were "licensed" to perform duties in the other establishment although not actually employed by it.
This "licensing" now has greater significance, and the NHS sees it as a way to exercise control over clinical academics without proper regard to their medical school status. It is not disputed that hospital authorities should be able to control the work of all doctors providing a service to the patients within that hospital's walls, and it is accepted that all clinical academics must hold an honorary appointment, not least in order to be covered under the NHS Indemnity scheme.
However, the extent of that control as it affects clinical academics has not been clarified. Nor have the obligations of holders of honorary appointments ever been determined. It is argued that where an NHS authority is contributing financially towards an academic post, the holder of the post should provide value for money by undertaking a prescribed amount of clinical work. In recent years, however, faced with increased service requirements, fewer staff and restrictions on junior doctors' working hours, the NHS authority may well have sought to impose terms and conditions of such appointees to ensure greater commitment to their service work -Jthis, even where no payment is made.
Honorary appointments are being replaced with "honorary contracts". The basis for doing so is unclear. I can find no formal statute empowering health authorities to enter into them, and there is little guidance on the format they should take. Consequently, there is a whole variety of documents purporting to be "contracts" - but contracts of what? If it is a contract of service, it might be more appropriate for it to be with the individual's employer, the university or medical school, and not with the individual. After all, any financial contribution is paid by the NHS authority to the employer, not to the individual. If it is a contract of employment, as was determined in a recent judicial review, to what extent is it governed by the provisions of the Employment Rights Act 1996? If an honorary contract relating to an honorary appointment is terminated by the NHS "employer", could the appointee claim unfair dismissal, and what would be the effect upon his or her substantive contract of employment with the university or medical school? It has been suggested that the latter would cease through "frustration", ie for "some other substantial reason", but that has yet to be tested. This problem of dual accountability for clinical academics is potentially a serious issue, but it should not be viewed along with the others arising from the current management split.
Given that the NHS, universities and medical schools are legally separate bodies and that each university or medical school is itself a separate legal entity, there is another aspect that is not generally understood or even regarded as being of much significance until it affects an individual,by which time it is too late. This is the matter of continuous employment, which determines someone's eligibility for redundancy pay and to claim unfair dismissal. At present, service within the NHS is aggregated, and this enables doctors to change jobs without detriment to these entitlements.
Not so for clinical academics moving to or from the NHS or from one university/medical school to another. Such a move is often the only way to obtain promotion. In these days of increasing job insecurity, this could be of considerable importance to an aspiring doctor trying to gain as much experience as possible without jeopardising family and mortgage commitments. Arrangements exist for pension benefits to be transferred, so why does this anomaly remain with regard to these other entitlements?
The staffing problems created by dual accountability and responsibility in teaching hospitals are not restricted to clinical academics. Hospitals and medical schools employ other categories of staff, eg medical laboratory scientific officers or technicians, to do similar jobs often in the same room. But they are employed under different terms and conditions with regard to pension and leave entitlements.
Responsibility for the control and maintenance of the premises occupied by the hospital and medical school falls between two stools. Where a medical school occupies accommodation within premises owned and managed by the NHS and shares services such as heating, lighting and communications, its hands are tied by its "landlord's" building and maintenance policies. This has serious consequences, particularly when vital maintenance is not carried out, and the medical school's work is threatened. Under existing legislation, an employer is responsible for its staff's health and safety, but how can it perform that duty properly in premises that it does not control?
The funding arrangements for teaching hospitals and medical schools are extremely complicated because the money is allocated through two government departments. Much time, energy and money is spent determining who pays for what. Those NHS trusts in whose hospitals undergraduate students are taught receive special increments for teaching and research, the allocation of which is determined by the medical school under a formula agreed with the NHS. This involves the financiers in a considerable amount of time in determining the allocations at great expense.
The "one organisation" with responsibility for delivering health care, teaching and research would undoubtedly be complex. To function properly, it would need to be an entirely new one bridging the two government departments now sharing these functions. It would be managed by a board with senior academics and health service specialists, and its role would be to create and maintain a wholly integrated teaching and research hospital. Academic excellence would still be monitored by outside bodies with courses and examinations run in accordance with university and General Medical Council requirements. The royal colleges would continue to regulate postgraduate training.
The "teaching hospital" would then be just that: an environment where the training of doctors would be closely linked with the service they will have to provide and where the service would benefit, not just from the money that would be saved by having one controlling body but also from the improvements that would result.
The plans by the secretary of state for health for the development of the NHS over the next ten years are generally to be welcomed, but it is to be hoped that he and the secretary of state for education and employment will now consider the feasibility of establishing University Hospital NHS Trusts with a view to including these in this reorganisation. If the present anomalous situation is allowed to continue, there is a very real danger that the United Kingdom's role as one of the world's leading nations in advancing medical research and the quality of health care will be greatly diminished.
James L. Bowen retired recently as director of administrative services and personnel at Charing Cross and Westminster Medical School.
THE TIMES 7Jjanuary 16J1998opinion research ixJ 'Because of the reduction in a hospital's staffing, associated medical school staff are having to undertake more clinical work at the cost of their academic duties' Amanda Hutt