9. The need for assessment and review of doctors' workloads
6.41 All doctors, including Consultants, working in mental hospitals have heavy workloads, and we have already expressed the view that there is a continuing need for these workloads to be assessed and reviewed. Without assessment of the extent to which, and manner in which, a doctor is coping with his workload it will be very difficult to know whether any adjustment is necessary. Moreover a doctor's workload may be so heavy that under it his standards will imperceptibly fall and he will be unable to keep abreast of current thought and practices.
6.42 Not only is the need for such assessment and review in the interests of the patients and other hospital staff: it is also very much in the interests of the doctors themselves that their workloads should be reviewed and that their problems in providing a satisfactory service within a multidisciplinary team should be recognised. For example, if there had been a clear policy on Heather Ward that Dr. W would attend each week and review one or two patients each time he visited, his inability to do this because of his other commitments would have been brought to the notice of the Medical Executive Committee, with a request that he should be given additional medical help during the time of his greatest need. In turn, the Medical Executive could have used the information brought to it to strengthen their case in asking for more Consultants. Last, but not least, an open discussion of the problem at ward level within the multi- disciplinary teamwork would have ensured two developments which might well have prevented the critique and subsequent developments. Firstly, the junior nurses on the ward would have understood more clearly the Consultant's problems. For example, we were told by Mr. Weston that he thought a Consultant should give an hour a week to each patient on the ward. This is so totally impossible that the suggestion alone tended to discredit some of Mr. Weston's other comments and suggestions. If, however, he had known of the Consultant's problems in more detail, he would not have come forward with such an impossible proposal. Secondly, once it became obvious that the Consultant could not play a major part in developing ward policies, it would have been clear that the onus lay on the nurses to do so, and such time as the Consultant was able to spend on the ward could then have been spent in reviewing those policies and adding or adjusting the medical components. The establishment of agreed ward policies will help the doctors, for where they do not exist, doctors may well be called to deal with repeated minor incidents and problems because there are no agreed guidelines covering common situations.
6.43 The other point of view was forcibly expressed by the Consultant member of the District Management Team who gave evidence to us. (It will be recalled that there are five doctors in this Team and that no member of it has any psychiatric expertise.) He was asked whether he ever felt in relation to any of the 21 hospitals in the District that it would be helpful to receive assistance from someone with experience relevant to a problem. He replied, "No, I don't think so". There followed these questions and answers:-
"Q. You never feel a need to call for an objective view from someone with experience in the specialty you are looking at, and indeed managing?
A. No, I do not think so.Q. Some people might find it very surprising that you can manage something - I will not say about which you know nothing, because that would be a gross exaggeration, but about which your knowledge is certainly limited?
A. Yes, but the medical practice in British hospitals is that all Consultants are regarded as equals in the clinical sense, and that Consultants go through a very long process of training. They have to sit higher exams set by the Royal Colleges who have no connection with the Health Service, who are only interested in maintaining the standards of their particular specialty so one assumes that by the time someone has gone through this long period of training and elimination that they are competent to carry out their duty.Q. Really, it comes to this, does it not, Dr. CT, that it is inconceivable that a Consultant will be appointed in the present system who does not, for the remainder of his working life, carry out his job to the highest imaginable standards?
A. Yes.Q. Is that really the view of the district management team?
A. Well, it is my view.Q. Do you think it is shared by your colleagues?
A. Yes."
6.44 This Consultant explained that he served on the District Management Team as a representative of the Consultants.
6.45 It has been Said that the Consultant is accountable to his patient for his performance, but this is no safeguard if the patient is not in a position to call his Consultant to account. At St. Augustine's this is no safeguard whatsoever, and we doubt its efficacy elsewhere, for doctors must know that with the present complicated nature of much medical treatment in all spheres of medicine, many of their patients are quite unable to judge their doctor's competence, or the wisdom of his decisions.
6.46 Neither will a Consultant's conscience save his standards from falling. Most of the problems arise because the Consultants are unaware, whether through forgetfulness or overwork or ignorance of what needs doing, and not because they deliberately turn aside from their duty.
6.47 The Regional Health Authority, as the employer, can use its tortuous disciplinary procedure if a very serious breach of conduct is revealed, or the "three wise men" procedure if it is alleged that a doctor is physically or mentally incapable of carrying out his duties, but neither of these procedures are appropriate for ensuring that acceptable standards of performance are maintained.
6.48 The co-ordination of a Consultant's clinical skills with those of the other professions lies at the heart of the multidisciplinary team work which we have already outlined. It follows, therefore, that although the development and maintenance of a Consultant's clinical skill and competence is his own responsibility, this responsibility must be exercised in the light of the needs of the hospital at which he is working and with the help and guidance of his-colleagues, the Royal College of Psychiatrists and, indeed, the multidisciplinary teams in the hospital. Much of the review of his workload will occur automatically as a result of the keeping and supplying of the statistical information we have suggested in paragraphs 6.20 - 23. When adjustments in a Consultant's workload are necessary the problem should be referred immediately to the Regional Health Authority as this is the only Authority able to take effective action.
6.49 We are concerned with the problem in St. Augustine's only, and recognise that the problem is a national one. It must, and will, be grappled with on a national scale one day. In the meantime we are satisfied that the medical staff of St. Augustine's recognise he problems, and we hope that they will work out their own scheme to solve them. We hope, for example, that they will agree standards for the review of medication, the means by which it can be checked that the agreed standards are being maintained, and the steps to be taken if they are departed from.
09 February 2025
