Tuesday, 17 July 2012

Professor John Temple "The world has changed since the times these doctors were left on their own and we're keen to ensure there's a very clear chain of command. We expect them to work as teams, not as individuals." February 2000.

Professor John Temple. 
Saying all is well to the media while being made 
aware of supervision failures through internal communications.

Sometime ago during the reign of Professor Catto, a junior doctor approached me. She detailed the failure of supervision during that time period. I promised to approach Professor Catto with her concerns. Catto commenced the beginnings of what eventually became this study here by Professor Collins of Oxford University. 

"But the report warned: "We are extremely concerned that some foundation trainees are expected to practise outside their level of competence and without appropriate supervision. 
"This places patients at unnecessary risk and gives the trainee the message that suboptimal care is condoned, neither of which is part of the professional values and aspirations of a good doctor." 
It continued: "The belief by some that 'being thrown in at the deep end' remains an acceptable way to learn reflects a failure to recognise the centrality of safe patient care and a lack of understanding of the major advances in learner-centred education."

The actual findings of the survey done by the General Medical Council recently can be downloaded here. I am not certain that the findings of the actual survey reflect the screaming headlines today :). If the actual survey is read, the results show an improvement

"81.3% of trainees said they would rate the quality of clinical supervision in their current post as excellent or good. 3.5% said they would rate it as poor or very poor (n=51,127)"

I wouldn't be convinced by any kind of research the GMC has its paw prints over. For a start juniors would be too fearful to be critical of their seniors. 

Nevertheless, here is a blast from the past when I raised concerns about failure of supervision in 1999 [ See enclosed article below]. The then Professor John Temple denied the time of day. Of course, recent results of research in 2010 show how wrong he really was. Nevertheless, Professor Temple knows that blowing hot air into the media does the trick in persuading the world into a false sense of security. Here he is working with the GMC on the  European Working Time Directive  . Of course, Professor John Temple was historically responsible for junior doctors at Mid Staffordshire NHS Trust and North Staffordshire NHS Trust - the two places with historically the highest mortality rate this decade.

We should therefore ask the General Medical Council that despite reports on a certain ward concerning a failure of supervision, why wasn't Professor Temple or Consultant Dr Monica Spitieri held accountable for placing patient safety at risk? If the General Medical Council of course cares so much about junior doctors supervision and their impact on patient safety then surely they would have taken action in 1999. The records show that in both hospitals - North Staffordshire and Mid Staffordshire, Professor Temple just turned a blind eye. Documents in my possession shows that despite Professor Temple's statement to the media, he was made aware of a failure of junior doctors supervision at North Staffordshire NHS Trust. The document is here. 

I would say that the GMC survey is merely lip service. Secondly, I suspect the problem of failures in junior doctor supervision is considerably worse than stipulated by excellent study by Professor Collins. Secondly, the GMC has never taken any responsibility for the failure of supervision. Indeed, when I first informed them of it, they turned around and questioned my competence. Of course, the General Medical Council eventually were forced to back down on their stance. See documents here

Of course, both the GMC and Professor Temple will huff away citing these events as being "historical". The essential point here though is this - those who never cared about junior doctors supervision were directly responsible for placing patients at risk. The public should understand quite clearly where the line of accountability lies.  It lies with those responsible for the training of junior doctors. So far they have all escaped accountability for their failures for more than a decade. Few ask the question - why have junior doctors been left unsupervised for so many years? The studies or research will never answer that question.

I am unhappy at the way junior doctors are continually demonised by the media. There is a failure to understand that the GMC, the Deaneries and Royal Colleges have direct responsibility for the supervision of junior doctors. The patient risk and subsequent deaths have occurred because of the failures of these organisations. It is time the public held these organisations to account.


Birmingham Evening Mail 21st February 2000.

NB - please excuse the media style of this article and move onto the text in bold - Professor Temple's statements.

BYLINE: Paula Marsh

As the NHS is stretched to the limit, a former top junior doctor tells how the harsh reality of working in Midland hospitals drove her to quit the dream job she had longed for. Mail Health Editor PAULA MARSH reports.

DR Rita Pal had been a junior doctor for just two months when she began to despair.

As a newly qualified medical student, she had dreamed of becoming an accident and emergency consultant and, when she gained one of the top junior doctor's posts at a Midland hospital, she was over the moon.But as the weeks unfolded, Dr Pal claims that long hours in poor conditions with little or no senior back-up turned her daily routine into a nightmare.

"I went in there very optimistic," she says. "I had it all planned, I was going to finish my training and specialise in accident and emergency work. I was quite excited about it because I'd got the top job working under the clinical director."

It was to take just one emergency situation for Dr Pal to begin seriously questioning her vocation.

An 80-year-old woman with gall bladder problems had collapsed and Dr Pal claims she was alone on the hospital ward with only one nurse on call for over 30 patients.


"I'd been practising for about two months when I found an old lady collapsed on the bed," she recalls. "She was breathing but not responding and she needed fluids urgently.
"I was totally on my own. The registrar was at a clinic 20 miles away and wasn't answering his bleep, my senior doctor wasn't working that day and the consultant had disappeared.
"I needed a drip to give her fluids, but they didn't have one on the ward and the nurse said she had no staff to go and get one. I had no alternative but to get it myself."
Dr Pal claims the nearest drip was 15 minutes walk away from the ward and by the time she returned half-an-hour later the patient had deteriorated.
"I managed to stabilise the patient after about two hours," she says. "In the end I got a senior doctor from a different department to look at her.
"He explained that I'd given the fluid a little too fast so he helped to sort that out. Finally, the registrar arrived and the patient was a little better. I thought everything would be fine then, but it wasn't. Afterwards, she was found with septic shock and she died."
The traumatic incident was the first in a catalogue of disturbing experiences which Dr Pal claims took place across three Midland hospitals where she has worked over the last 18 months.
At one hospital, Dr Pal claims she was forced to watch a patient die because there were no endoscopy cameras to detect internal bleeding.
"There was a man who just bled and bled because there were no endoscopy facilities," she recalls. "Nor were there any intensive care beds and in the end he died.
"The worst part was that this sort of thing happened so many times. When I told my registrar I didn't want to do medicine any more, he said I had to learn to let go and stop being so emotional about my patients. But it's soul destroying."
Not only was Dr Pal struggling to cope with making life and death decisions while working alone, she often found herself battling to stay awake.
The young doctor, who lives in Sutton Coldfield, recalls being stopped by police twice for falling asleep at the wheel.
"The hours were an absolute nightmare," she says. "Forty hours a week is a non -existent entity. Most of the time I was doing 72-80 hours a week and friends I have working in the NHS are still doing the same kind of shifts.
"You could work continuously for 48 hours on a weekend and then do the whole of Monday. They get round it by saying you get six hours protected sleep, but you never do because you get bleeped at all hours of the day and night. I never had an undisturbed sleep the whole time I was on call.
"You get to the stage when you make mistakes because you're nearly asleep.
"It also makes driving home really dangerous.
"On two occasions I was stopped by the police driving home and they made me get someone to come and pick me up. On another occasion I had to stop at a service station for a few hours."
After one particularly long weekend shift Dr Pal was so tired she was found fast asleep on the pavement by her car.
"I was absolutely exhausted, but when I got to my car it had been clamped," she says. "I just thought, I'll have a rest and I sat down on the pavement. The next thing I knew I was being woken up and it had started to get dark."
After a year of what she claims were traumatic working practices, Dr Pal was finally awarded General Medical Council registration. Immediately afterwards, she quit full-time hospital work.
Now she supplements her full-time law studies at Birmingham University by working as a West Midlands Police doctor and a locum.
"It's easy for me to speak out now because I have no longer got anything to lose," she says. "People are so frightened of losing their jobs that the stories which do get out are only the icing on the cake.
"People put their trust in hospitals and that trust is sometimes being abused. Nurses are short staffed and over worked and there are not enough intensive care beds.

"You only need to look at the recent flu epidemic to see that drastic action needs to be taken to prevent the scales of an already exhausted system tipping towards catastrophe."

Expert defends quality of health service
A TOP Midland health professor responsible for training junior doctors today insisted that the health service provides a "superb" quality of care, despite the extreme pressures facing hospitals.
Professor John Temple, regional post graduate dean for the West Midlands NHS Executive, says extensive work is being carried out to ensure that junior doctors are properly supervised. 
And he adds that while there was a shortage of doctors in the NHS the system was managing to cope "remarkably well". 
"Over the last five years one of the things which has changed quite dramatically is that doctors are supervised properly," he says. 
"All junior doctors should be supervised and they're required to know who they should contact and how in times of emergencies. 
"The world has changed since the times these doctors were left on their own and we're keen to ensure there's a very clear chain of command. We expect them to work as teams, not as individuals."
Prof Temple says that while the health service was clearly under pressure, hospital managers were succeeding in delivering high quality care.

"We are under-doctored but we are increasing the numbers through medical schools and bringing doctors in from other countries.

Very effective 

"All this is to ensure that our medical units are properly staffed.

"We live in a very high-tech world where treatments are very effective but very expensive and the acute service is very busy throughout the year.

"The hospital service responds remarkably well to these pressures and we still deliver a superb quality of acute care."

Prof Temple says the issue of working hours was constantly being addressed in the region.
But he insists that managers are now winning the battle against long hours and says no doctors should be working the kind of 80-hour shifts that have been reported in the past.
"We've worked very hard to get doctors down to a maximum of 56 hours but we know there are instances where those hours are extended for very genuine reasons like patient care.
"We're constantly working to make sure we get those hours down and we're much closer to it now."
He says that hospitals found to be flouting the guidelines were reported to a regional task force working to implement junior doctors hours.
"We have a monitoring team which inspects hospitals on a bi-annual basis and we liaise closely with the task force on working hours," he says.
"We don't punish hospitals where doctors are found to work longer shifts but we work with them to try and rectify the situation."
Pay campaign to cut hours

CHAIRMAN of the British Medical Association's Junior Doctor's Committee Dr Andrew Hobart claims hospital trusts are taking advantage of low-paid staff in an effort to cut costs.

The accident and emergency specialist, who works at Walsall Manor Hospital, is heading a high-profile campaign to increase the pay of junior doctors, which he claims will help reduce working hours.

"The sort of working practice Dr Pal describes was meant to be outlawed by 1996, but it clearly wasn't - which is why the BMA have launched a renewed campaign," he says.

"We strongly believe that one of the reasons for these sorts of hours is the pay structure which gives employing trusts a perverse incentive to make junior doctors work as many hours as possible.

"We've been trying to negotiate a different pay scheme which places more value on out-of-hours work and brings in penalty rates for really excessive hours.

"The negotiations have been stalled, but we feel there may be some progress shortly."

Dr Hobart says that another major problem facing the NHS is the lack of senior consultants and nurses in hospitals.

And he adds that far too many trusts are now employing inexperienced "care assistants" to do the work of fully-trained nurses.

"Patients should have access to the best possible medical care which means fully trained specialists and consultants and an adequate level of nursing staff," he says.

"Out of hours the NHS is incredibly reliant on junior doctors, particularly the very junior ones.

"It's not that the consultants are lazy, it's simply that there are not enough of them. They are having to work like mad to meet the Government's waiting list targets every day and in addition they're responsible for large numbers of emergencies.

"The system is geared towards daytime working but patients don't just get sick 9am-5pm Monday to Friday.
"We need a system which has dramatically more consultants doing slightly less during the daytime in order to be available for more out of hours work.

"Staff levels differ incredibly between hospitals coping with the same number of patients.

"Some hospitals have gone far too far down the route of replacing nurses with care assistants which is fine if everything is going swimmingly but it only takes one critically ill patient to use up the capacity of staff. If there are two very sick patients then you're stuck."


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