By CivilServiceWorld

08 Jul 2013

A hospital doctor says government edicts and the fear of litigation are limiting medical staffs’ freedom to learn their trade and act in their patients’ best interests. Tom Barfield reports.

“I work at a large North London hospital as a senior house officer, which means I’m in my second year as a junior doctor. My experience across a few different institutions has been in A&E and acute admissions, spending a lot of time on paperwork.

The hands-on doctoring I do is mostly limited to routine investigations like taking blood and lumbar punctures. This seems to be a consequence of a litigation-averse culture in the NHS: junior doctors are increasingly scribes and blood-takers, rather than having the kind of supervised freedom that those who are now seniors enjoyed at our level. Too many juniors aren’t given much responsibility, and this will have knock-on effects on our capabilities as we move up the ranks.

We’re also affected by the Working Time Directive, which officially limits us to 48 hours per week, and can cause problems when there’s a particular patient who unavoidably needs more of your time – you can actually get in trouble with managers for staying too long.

Everyone feels the time pressure, particularly with the four-hour target for treatment or discharge in A&E. There are days when that target simply can’t be met, as there’s no way to predict how many patients might come in with problems that have to wait while we deal with more acute cases. The target has focused minds and got A&E doctors multitasking more, but it can be tough when there aren’t enough beds or you’re covering a ward as well as A&E.

Working in a big hospital means we benefit a lot from the consolidation in recent years of specialist services – such as vascular surgery or renal medicine – into large regional centres. Everything’s on-site and there are top experts available, so we have to make many fewer referrals and transfers. My gut feeling is that this must improve patient outcomes, especially for those with conditions that cut across specialisms.

At hospitals without those facilities, things can get difficult. Without on-site cover by doctors specialising in their condition, patients have to go through time-consuming transfers to other hospitals. If their paperwork gets lost they can end up spending longer than necessary as an inpatient and run a greater risk of hospital-acquired infections, such as MRSA.

These infections are subject to national targets for getting numbers down. Hospitals are penalised for cases where patients’ blood test results show the presence of MRSA, but these don’t necessarily prove that they have the infection: it might simply be present on their skin, in which case it’ll contaminate the blood test. Often this means pressure from management to avoid doing blood tests on patients in areas where MRSA has been found – a fine example of a perverse incentive.

The pressure to minimise antibiotic use is also challenging, as too short a course can mean patients developing resistant versions of the bugs for which we’re treating them. National policy prioritises limiting the development of antibiotic resistance in specific superbugs such as Clostridium over giving patients the best treatment and letting doctors make the best decisions case-by-case.

Meanwhile palliative care is becoming a political football, which makes me uncomfortable. In my experience, patients and relatives don’t like making decisions about placing people on DNR [Do Not Resuscitate] or the Liverpool Care Pathway [LPC – the palliative care guidelines for terminal patients], and are relieved to know doctors have the final say. You need years of experience to anticipate outcomes in these situations, and it’s difficult for us because we’re trained to treat people for diseases, not to admit there’s not a lot more that we can do.

It’s been frustrating to see calls for a parliamentary debate on palliative care, because most lawmakers don’t have a clue of what we go through when we make that call. There have been a few high-profile cases where patients or their families have been unhappy with the offer of palliative care, as they see it as doctors giving up on them or their loved ones.

The fear of this kind of publicity shouldn’t scare politicians into further constraining our freedom to treat people appropriately. The headlines are already affecting doctors’ decisions on placing patients in palliative care.

The practice of medicine should be determined by compassion and evidence, not the strength of public outcry or the editorial columns of newspapers. Doctors need the freedom to practise their profession.”

A regular column in which people explain to civil servants how government policy affects their working lives.

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