Respect. Engage. Change.

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Part of Time to Think Differently

Type 'define an NHS consultant' into Google and you'll get more than 5 million results – none of which actually crystallises what the role involves. It's a term that’s ever more shrouded in ambiguity as the NHS morphs and changes while moving into the unknown future.

So what exactly should the role encompass? Should consultants simply run their specialist clinics at the time of their choosing and then walk away? Should they lead and develop a service? Or should they do more? When patients are asked for their views, most, if not all, have asked to be 'treated as a person, not a number'.

So, how about five roles that we would like to see a consultant of the future hold?

Specialist: Perhaps we need to accept that there are some areas where specialists are better than anyone else. It wouldn't be good for patient care to ask someone else to do a specialist's job, (and besides, taxpayers' money has been spent to learn those particular skills). A case in point – setting up insulin pumps for antenatal diabetes requires specialist training and should remain the responsibility of specialists to ensure that a high quality of care is maintained.

Educator: We should also accept that in the present economy we cannot afford a system in which every patient sees a consultant. A specialist needs to hold a role as an educator, with general practice acting as the first port of call. Be it with trainees or qualified physicians, a specialist can contribute significantly to improving the health care of a patient by using virtual methods, case discussions or even reviewing patients with the local practice nurse or GP. Build relations, help to educate and inspire the next generation to follow your example – these have to be the primary goals for a consultant.

Leader: Consultants should be concerned with the leadership of the whole system, not just their own services. If we genuinely believe that we need to 'do something' to improve public health, perhaps consultants should become the focal point for leading changes in schools and colleges; become active public health campaigners; promote sports in schools, encourage early diagnosis, and educate the public? In spite of everything that is said in the media, the public still respects the opinion of a doctor, so why not be at the forefront with the media, hospital communications, and local councils?

Accountable officer: This leads on to the question – is there a willingness among specialists to be accountable for the outcome of services? If data suggests that something isn't right, perhaps it's better to accept it and try to make the necessary improvements rather than challenging the data or treating it as a conspiracy.

Patient representative: Finally, what can a consultant do for a patient? Can we take down the barriers and be there when needed? Are we bold enough to look past the traditional ways of holding clinics, and instead offer patients slots when they want them, or even communicate with them by email, video links or phone? Indeed, why can't we listen to what patients want in their services and then try to lead the changes needed? Why can't we try and get past the age-old view of 'I know best'. There are too many examples of the 'aloof' consultant, who has little time to speak directly to patients. The days of 'us' seeing patients on our own terms is – quite rightly – dying a slow death. We need to ensure that we can rise to the challenge and use existing forums to suit patients – especially as a disease progresses where engagement should be the key mantra.

In the words of Lao Tzu 'If you do not change direction, you may end up where you are heading'. As specialists, we continue to mull over where we are heading. Maybe it's time for us to make sure we lead the change in direction – and perhaps the first step is to redefine what we do.

Dr Partha Kar has been the Clinical Director of Diabetes since 2009 in Portsmouth Hospitals NHS Trust,  part of a national award-winning department based on inpatient diabetes care.

Comments

Dr Linda Hutchinson

Position
Consultant paediatrician and commissioning advisor,
Comment date
21 February 2013
An interesting post. I sense your frustrations and can imagine the personalities and different situations you allude to. There is much to comment on.

Hospital consultants are expert advisors on their area of specialty. The advice can be direct to a patient, to others in their team or hospital or to colleagues in other parts of the health or care system. Similarly, they will have technical skills relevant to their specialty. And hopefully the wisdom to know when to apply these or when not.

But they are not experts in everything and should not expect or be expected to be. Most will be good at team leadership, some very good, some at wider management, finance, some at change leadership or in being great educators. Others will not.

I question whether they should be the ‘focal point of leading changes in schools and colleges’ as the skills and perspectives of public health, GPs, teachers and others are equally or more important. I certainly advocate them taking part in initiatives and dialogues beyond the hospital walls though.

On your aloof consultants and the ‘I know best’ attitude, I find it helpful to take the long view. Thirty years ago doctors did not tell patients when they had cancer, twenty years ago we didn’t collect any patient feedback, ten years ago we were only starting to hear about human factors training, situational awareness and checklists. I think we are going in the right direction, just need to go faster and make sure everyone is on the bus.

Hugh Rayner

Position
Consultant nephrologist,
Organisation
Heart of England Foundation Trust
Comment date
21 February 2013
Dear Partha
This is very nicely put. Such a job description would make a most stimulating and satisfying post. Most of us wish to leave things better than we find them and this type of role would leave an important legacy.
Is the second step to redefine the employment base from the hospital to a local 'system' employer and so break the link of consultant episodes with income?

Craig Wakeham

Position
GP,
Organisation
Cerne Abbas Surgery
Comment date
22 February 2013
Karl Popper said in the introduction to his seminal text 'The Logic of Scientific Discovery'; Philosophers should not be specialists. For myself, I am interested in science and in philosophy only because I want to learn something about the riddle of the world in which we live, and the riddle of man’s knowledge of the world. And I believe that only a revival of interest in these riddles can save sciences and philosophy from narrow specialisation and from an obscurantist faith in the expert’s skill, and in his personal knowledge and authority; a faith that so well fits our ‘post-rationalist’ and post-critical’ age, proudly dedicated to the destruction of traditional rational philosophy, and of rational thought itself.

The Independent Commission on Medical Generalism also made some compelling arguments for a more holistic approach to the care (as opposed to cure, which is only a part of care) of patients.

Then we have Balint's seminal concept of the collusion of anonymity, which in my experience is flourishing in the increasing complexity of modern medicine.

Specialists DO have a key role in helping to develop service but they need to learn to collaborate and not to seek to own and control (which is too often my experience). They should seek to support and empower the broader professional teams involved in a service. A key role of a specialist should be to improve the understanding and skills of generalists and other team members. A good leader also knows when to be led.

Mick Smith

Position
Chairman,
Organisation
HAVO (Infrastructure charity)
Comment date
22 February 2013
I am writing as a patient and so definitely not an expert.
I must say I comme4nd the system that has, over the years made consultants/specialists/Mr's into actual caring humans, rather than the toffee nosed idiots who had to shout at everybody.

As a 'customer' of the service I want a person who I trust to know all there is to know about my condition who I can trust to advise me and treat me purely on my needs rather than which administration is in power at any given point in time as is usually the case in my experience.

Yes, I agree wholeheartedly with the thrust of what has been written above but I do stll want to have an expert that I trust that I can turn to; rely on to offer me the best the NHS can afford at the time.

That person though, ought to be available where I live as far as is possible. I live 18 miles from my hospital as to many hundreds of other customers (yes we ARE customers, because we have the right to complain and during our lives we paid for the servuiices we use) who have to have a car and enough money to pay NCP shareholders their dividends. There is no bus service that actually goes to the hospital the nearest it gets is a quarter of a mile down a steep hill.

Here's a thought: instead of 500 customers travelling to the hospital, why doesn't 1 consultant drive to where we live? That works out cheaper surely?

Yes, I agree with email and telephone engagement if a mere set of questions will give the consultant all she needs to know about how you are recovering, or, how well you are doing following her treatment. That in itself will never be enough.

I am also in favour of a more holistic approah to getting to the root cause of the problem rather than simply dealing with the symptoms as that throws up some really silly scenarios: I suffered a perforated ulcer (not the best diet plan I ever trried but very effective). Clearly, this seems to have been caused by the anti-inflammatory's I had been taking for over ten years dues to osteo arthritis in sevreal places.
As a result I have to take opiates with the result that I am now suffering chronic constipation. I also suffer from CopD - my fault so shuttup about it - now, here is the funny bit: Every day I sit straining and straining until I chieve heaven... yet, on my annual visit to the Athsma nurse I was not allowed to blow into the machine to test my lung capacity IN CASE I DAMAGED THAT ULCER DUE TO THE STRAINING! Sorry I shouted.

That is where we need to think differently; where we need to research; where we need to suffer the cost and get to the cause of the pain and deal with that.

That is a different way of thinking I suggest that might actually show some favoyurable results - even if it does cost a bit more.

Thank you
Mick Smith

Linda Dell'Avvocato

Comment date
22 February 2013
I agree with Dr Par's 5 main points - essential that consultants retain their humanity with their patients and all colleagues. In light of the increasing evidence of bullying within the NHS consultants must be accountable for patient care - any elements of negative cultures should be raised at the most senior levels as standards of patient care will suffer. Leadership, positive role modelling and educating all is a key function of a consultant as often small chunks of advice makes a huge difference to patient's lives. The specialist role is really what makes a consultant -the breadth of knowldege and experience - key is the delivery and style of communication - as patient's confidence and well being can be dashed by a poor communicator.

James Haddow

Position
Specialist Registrar General Surgery,
Comment date
22 February 2013
Professionalism in medicine will continue to evolve as society changes and I think the above is a pretty good signpost to our preferred destination.

To expand on the relationship with the patient this is the area where our teaching has not yet changed at all and has the furthest to go. Bedside manner is taught religiously, and more recently there has been a focus on training doctors to have good communication skills. By the time we are seeing and treating patients, we know how to conduct ourselves, we know what to do and say and we always get it right. Or do we? How do we know?

I know of no one who asks for feedback on their own bedside manner. Shouldn't it be part of our practice to say, "How did I do today Mrs Smith?" or "Your feedback is important to us, please could you put your comments in the box on your way out"? They do it in the shops. All the phone and utility companies do it every time I call them.

Patient feedback shouldn't be just something the organisation collects on a annual basis. It should be part of routine practice.

carolyn johnston

Position
Anaesthetics SpR,
Organisation
South West London
Comment date
23 February 2013
A very interesting and stimulating debate! Someone fitting the suggested features of a 'consultant' above would be a valuable asset to any organisation.

A related question is: do all fully trained doctors need to display all of these features? Especially in the areas of leadership and accountability: what is the role of a fully trained clinical expert who does not wish to fulfill these roles? Can they be a consultant?

In the current system, all hospital medical trainees can reasonably expect to become consultants on completion of training. I am not sure it is possible for all of them to meet the description above.

Corinne Aspel

Position
Lead Senior Nurse Patient Experience,
Organisation
TEWV NHS FT
Comment date
25 February 2013
As a nurse with considerable expereicne of working in the NHS I would support the development of these roles further for Consultants. Whlilst specailist skills can be shared and others taught procedures we need Consultants to be at the forefront of the changes within the NHS. I am currently also a patient and last week had an urgent appointment with a consultant who was pleasant and introduced himself and shook my hand then spent spent most of his time looking at the computer repeating everything my GP had already told me, asked me nothing about my medical history or presenting problem or in fact anything about me as a person , he looked at the scan knew as I did that I would have to have another investigation ( Map of medicne is very useful! ). I guess from a technical perspective he did his job and I am getting the right investigations. But no real discussion about the fact that I may have a life threatening condition how anxious I had been and contiune to be whilst waiting to find out what is wrong. Sadly this is all too often the experience of too many people.

Dr Suparna Das

Position
Consultant anaesthetist,
Organisation
South London Healthcare NHS Trust
Comment date
25 February 2013
Well said Partha. As senior doctors, consultants not only need to have clinical expertise but also demonstrate qualities of good clinical leadership - leading by example and leading from the front. The key to this is a bottom-up, distributed model of leadership rather than a top-down one. 'Medical leadership isn't about how to control doctors but about getting doctors to control the system' - I understand this is a quote from a talk by Prof Richard Bohmer of Harvard Business School who is also a visiting fellow at the King's Fund.

Damian Roland

Position
NIHR Doctoral Research Fellow,
Organisation
University Hospitals of Leicester NHS Trust
Comment date
25 February 2013
This is obviously a timely post but I wonder if I am being niave in suggesting when was it that Consultants stopped being specialists (even if specialist in generalism itself) , educators, leaders or patient advocates. With the exception of accountable officers do not all these things embody what all patients expect in their consultants.

Perhaps there is not enough time to practice out of all 5 to optimal performance but should we not be expecting this now not in the future...?

Partha Kar

Comment date
26 February 2013
Perhaps so..but from some of the responses above, it seems we have forgotten to do so.- or at least for sure, not all of us do so.
And yes, we should be doing so now...but what is now an exception hopefully one day becomes a norm.
We live in hope.

Robert Varnam

Position
GP + Clinical Lead,
Organisation
NHS Institute
Comment date
26 February 2013
I think the world's moved on, in ways that require us to broaden this definition. Increasingly, our patients have multiple overlapping problems, which we cannot cure.

These problems require us to be enablers, as well as specialists. Our patients with long term conditions are themselves their chief care delivery system. They need us to share knowledge, decisions and power with them, and to increase their knowledge, skill and confidence to care for themselves effectively.

Personally, this challenges the professional identity I was trained for. But if our patients have a call on us, they have the right to call out the courage to step outside the traditional expert role. Sometimes, telling people what to do is the least effective thing we can do.

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