Posted by: Witch Doctor | January 9, 2008

Tooke Inquiry – The role of the doctor



Universities are the coalmines of the 21st century”

Yes, Health Care and Education have become commodities.

Just like coal.

And the role of the doctor at every stage in their career must be clearly defined, before it is defined by global economic forces.

And the medical profession must remove their kid gloves while it is being defined.

Mustn’t they, My Black Cat?



Here is what Tooke says about defining the role of the doctor.

No apologies for the length of this post. The Witch Doctor thinks the Tooke Report is one of the most important documents produced since the birth of the NHS.

The bold italics are mine.


“Service needs cannot be met now or in the future unless there is a clear understanding of what part each healthcare professional plays. This is particularly true for doctors and needs to be articulated for each career phase, including doctors in training and those certified as having completed specialist training.

Without such definitions it is impracticable to pursue outcome focused medical education or attempt to plan the workforce. The Inquiry revealed evidence of non-resolution of these fundamental definitions, and a lack of acknowledgement of the essential professional attributes the doctor brings to the healthcare team.

The doctor’s role as diagnostician and the handler of clinical uncertainty and ambiguity requires a profound educational base in science and evidence based practice as well as research awareness. The doctor’s frequent role as head of the healthcare team and commander of considerable clinical resource requires that greater attention is paid to management and leadership skills regardless of specialism. An acknowledgement of the leadership role of medicine is increasingly evident.

Role acknowledgement and aspiration to enhanced roles be they in subspecialty practice, management and leadership, education or research are likely to facilitate greater clinical engagement. Encouraging enhanced roles will ensure maximum return, for the benefit society will derive from the investment in medical education.

Greater acknowledgement of the service contribution of trainees will help reverse the emerging trend wherein some young doctors in training seem to see themselves as trainees first and doctors second.

Interim Recommendation 5 associated with this issue was very strongly endorsed, with 95% of e-consultees agreeing/strongly agreeing and only 1% disagreeing or strongly disagreeing:
Interim Recommendation 5
There needs to be a common shared understanding of the roles of the doctor in the contemporary healthcare team. Such clarity must extend to the service contribution of the doctor in training, the certificated specialist, the GP and the consultant. Such issues need to be urgently considered by keystakeholders and public consensus reached before the end of 2008. Education and training need to support the development of the redefined roles.

The concerns expressed in this section resonated strongly within the profession. There is a collective sense that the acquisition of responsibility by doctors in training is ‘being pushed to the right’. It is taking longer before appropriate responsibility under appropriate supervision is being taken. Role clarity is required for all doctors including those in SAS grades and locum posts.

The consultation also revealed evidence that education and training opportunities for doctors were being diminished by such experiences being used for other healthcare professionals substituting for medical practitioner roles. Although such skill mix solutions may be superficially attractive to meet service performance imperatives, they call into question the clarity of role of other contributors to the healthcare team, and whether role ‘substitutors’ have the necessary educational foundations to execute the roles to the required high standards. EWTD will increasingly make it harder for medical trainees to be exposed to sufficient training opportunities, further compounding this problem. It follows that given that contemporary healthcare relies upon multi-professional teamwork, clarification of the role of the doctor (and the education and training implications that stem from such an analysis) must be accompanied by similar clarification of the roles and training requirements for other professional ‘clusters’. Given that other professions are to embark on ‘modernising’ their own ‘careers’ it is strongly recommended that such analysis precedes such work.

The service contribution of trainees (including undergraduates, appropriately supervised) needs to be recast as an integral part of their training, supported by highly professional education and feedback which Trusts/hospitals are motivated to provide.

Some reassurance, however, comes from a recent survey conducted since the Interim Report which suggests that more than 85% of young doctors feel they are making a significant contribution to patient care. The contemporaneous review of Tomorrow’s Doctors, the GMC blueprint for medical undergraduate education, provides an opportunity to explore whether greater and more challenging service experience can be gained under appropriate supervision during the later stages of the undergraduate programme. This would promote earlier acquisition of responsibility and compensate in part for lost exposure through EWTD.

As with the consultation response to Unfinished Business, considerable concern focused on the nature of the CCT holder, the contemporary interpretation of the consultant role and fears regarding the creation of a ‘sub-consultant’ grade. The specialist/consultant debate needs, in the view of the Panel, to separate out issues of nomenclature and terms and conditions from functional roles.

In the Panel’s view CCT holders must be capable of independent practice in their specialty area. In the past on completion of specialist training and appointment as a consultant, individuals often assumed a broader set of responsibilities e.g. for service development and management, regardless of their attributes for such roles. Most consultants on appointment today are joining a team and it is unlikely that they will lead service development in the early years of their tenure. There are several implications from this analysis:
i) The ‘consultant role’ may be variously interpreted.
ii) There needs to be professional preparation for the enhanced roles to which consultants aspire e.g. in education, management and research.
iii) Not all consultants will aspire to, and/or have the attributes to pursue enhanced roles.
iv) Hospitals (and GP partnerships) will have an increasingly clear view of the contribution they wish the new appointee to assume; in some specialties this may mean the assumption of a set of responsibilities commensurate with the historic role of the consultant, in others a more confined service provision role may be preferred.

If this new interpretation of the consultant role can be acknowledged, the nomenclature does not need to change, rather the functional content made more explicit. If the consultant contract is used as intended to facilitate pay progression primarily on the basis of contribution rather than seniority this too does not need to change, nor does a new specialist grade and contract need to be negotiated. Clarity on these issues is urgently required to provide trainees with clear goals and to inform the educational preparation required for enhanced roles.

The broader issue of the roles of the doctor in the contemporary healthcare team, and how this relates to other members, needs wide discussion and societal engagement. Several consultees commented that it would be difficult to reach resolution on such important issues by the end of 2008. In the Panel’s view resolution is urgent given the current Review of the NHS which must reflect on the contribution of members of the healthcare team.

Although such clarity is necessary for planning purposes we accept that it is an issue that needs continual review as the different roles evolve.

In the light of consultation the Final Recommendation 5 has been amended as detailed below:

There needs to be a common shared understanding of the roles of all doctors in the contemporary healthcare team that takes due account of public expectations. Given the interdependency of professional constituents of the contemporary multiprofessional healthcare team we suggest a similar analysis extends to other healthcare professional groupings. Clarity of the doctor’s role must extend to the service contribution of the doctor in training, doctors currently contributing as locums, staff grades and associated specialists, the CCT holder, the GP and the consultant. Such issues need to be urgently considered by key stakeholders. Notwithstanding the need to keep such a key issue under constant review, stakeholders should seek to reach public consensus before the end of 2008, so important is the issue for current NHS reform.

Education and training need to support the development of the redefined roles for each professional grouping and provide the necessary educational foundations to enable them to practise safely and effectively, and to aspire to enhanced roles.

Several professional constituencies have started work on this pivotal issue including the Royal College of Physicians, the Medical Schools Council, the BMA, and others.

Work is also being conducted by the NHS Review team on this topic and the related consideration of the roles of other members of the healthcare team.

A meeting is planned for 21/22 October 2008 to celebrate the 150th Anniversary of the Medical Act of 1858 to draw together the various workstreams and hopefully to establish consensus.”




We’ll keep this important stuff up for a few days while we have a break.

The Witch Doctor needs to swot up on the very challenging Ancient Bottle Spell in case the government decides to fudge Tooke and the NHS heads for dire times.

Eh, My Black Cat?

The Witch Doctor – Link to a random page





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