Sunday, September 23, 2007

Brits not allowed to prefer British doctors

The threat of unemployment among UK medical graduates is being blamed on the failed computerised recruitment system (MTAS), but an article in this week's BMJ argues that the real problem is government policy on medical immigration.

In the late 1990s UK medical schools produced nearly 5,000 graduates each year, considerably fewer than the NHS needed, writes Graham Winyard, a retired Postgraduate Dean. But in 1997, an expansion of medical school places began and the number of graduate doctors is set to rise to 7,000 in 2010, an increase of 40%.

The planners assumed that UK qualified doctors would replace those from overseas. But Government immigration policies have encouraged thousands of overseas doctors to compete for postgraduate training posts, and it is of course illegal for trusts and deaneries to discriminate on the basis of country of qualification when making appointments. Expanding medical schools makes little sense if extra graduates cannot pursue a career in medicine, says Winyard.

UK trained doctors began to voice concerns about possible unemployment in 2005 and these concerns were dramatically realised this summer, when MTAS was introduced to select doctors for training posts. While there were broadly sufficient posts to accommodate UK applicants, together with those from the rest of the European Economic Area, he argues, the inclusion of thousands of overseas doctors has transformed the prospects for all applicants and has made widespread failure to secure a proper training post inevitable.

The UK urgently needs policy coherence on immigration and medical training, he writes. The direct connection between policy on medical immigration and the likelihood of unemployment for UK medical graduates is inescapable. The most obvious action, he says, would be to suspend the Highly Skilled Migrant Programme - a scheme allowing highly skilled people to migrate to the UK to seek work without a specific job offer - as it applies to doctors, and establish a two stage recruitment process similar to that used in other countries, whereby overseas applications are considered after those of domestic graduates.

The rights of overseas doctors already in the system must be safeguarded, but if decisive action is not taken the situation will be worse next year, he warns. This muddle is in no one's best interests and needs open and honest discussion and clear leadership, however difficult that may be, he concludes.


Australia: Surgeons say NSW public hospital unsafe

THE head of surgery at Mount Druitt Hospital says the hospital is unsafe and has accused the Health Department of covering up the death of a patient who waited 14 hours to be moved to another hospital because Mount Druitt has no intensive care unit. In a letter obtained by the Herald, Mac Wyllie said the department's claim in an internal report that the delay "did not affect the outcome" of the patient's condition was "'inappropriate" and "deliberately misleading". The 68-year-old man died of acute pancreatitis the day after arriving at Westmead Hospital's intensive care unit from Mount Druitt on March 3. "Our [surgeons'] alternative conclusion is that this delay did affect the final outcome of this patient who eventually died," Dr Wyllie said in his letter to the Sydney West Area Health Service, dated September 5.

Surgeons have been warning for the past three years that Mount Druitt Hospital's emergency department is unsafe because it has had no intensive care unit since early 2004, when it was closed due to staff shortages, and the high dependency unit, where the man waited for the transfer, has no full-time medical staff. They say even "remotely unwell" patients must be transferred to Blacktown or Westmead hospitals. They are concerned that local people, among Sydney's most disadvantaged, wrongly believe the "emergency" sign at the front of the hospital gives the impression it can admit acutely ill patients, which it has not done since October 2004.

The Premier, Morris Iemma, who was then the health minister, promised that patients would not wait for transfers as a result of the intensive care unit closing and that the high dependency unit would have consultant supervision. Apart from cardiology, rehabilitation and pediatric services, Mount Druitt has no acute medical beds and no full-time general staff physician, or even an on-call general visiting physician.

A patient presenting with conditions such as a diabetic complications, breathing problems, chronic arthritis or a stroke must be transferred. Accident and emergency specialists are confined to that department, which is also understaffed. A senior doctor at the hospital, who did not want to be named, told the Herald: "Since 2004 there has pretty much been a whitewashing at Mount Druitt Hospital." He said the man who died "had deteriorated quite significantly" while waiting for the transfer.

Critical cases were not brought to Mount Druitt, but for the "isolated cases" that do end up there, "there is no question that they are in danger - quite considerably - which has been shown by this case and others".

However, local residents are staunchly opposed to closing the emergency department and it would be a political nightmare for the State Government. The Government has ignored its own, independent General Metropolitan Clinical Taskforce, which recommended in a February 2005 report that the department be closed and noted that the community's "perception" that it was a 24-hour, comprehensive service "needs to be addressed". "Mount Druitt Hospital still remains unsafe and the clinicians find it increasingly difficult to fully exercise their duty of care to the patients of Mt Druitt," Dr Wyllie said in his letter, which he addressed to the deputy director of clinical governance at the Health Department, Dr Andrew Baker. Dr Wyllie did not supply the Herald with the letter.

He said the Sydney West Area Health Service Root Cause Analysis (RCA) report on the man's death had "fundamental flaws and omissions". It was more than 15 hours before the man saw an intensive care doctor, Dr Wyllie said. "To say that this delay did not affect the final outcome of the patient is not only inappropriate on the evidence put forward, but could be construed as deliberately misleading," he said. The report failed to take into account that the high dependency unit "has no dedicated residents and it has no direct supervision from either Blacktown or the Westmead intensivists". "I am advised that no intensivist has had a physical presence in the unit to supervise the treatment of patients for over three years."

The RCA report, seen by the Herald, said the man arrived at Mount Druitt Hospital emergency department at 7.30am on March 3, was diagnosed with acute pancreatitis and was to be sent to Westmead Hospital's intensive care unit. However, there were no beds available and he was moved instead to Mount Druitt's high dependency unit and did not arrive at Westmead until 9.45pm. He died early the next morning.

"It is unlikely that this delay altered the course of his illness." the RCA report said. Although the report said there were no intensive care beds at Westmead when nurses checked at 3pm and 5pm, when the man "began to deteriorate", it blamed the delay on "poor communication" within the emergency department.

Another senior doctor at Mount Druitt Hospital, who did not want to be named, said transfer delays were "inevitable" and "unnecessary". "The point is that you can't keep anyone who's even remotely unwell for monitoring at Mount Druitt," he said. "Politically, it's the right thing to say that you've got an emergency department but the fact of the matter is that this hospital has been so downscaled that if a person is really unwell, we can't keep them here.

But one of the authors of the General Metropolitan Clinical Taskforce report, Professor Kerry Goulston, said yesterday that the problem was not a lack of an intensive care unit but understaffing of the emergency department. "We said it was wrong 2« years ago to have a sign saying 'emergency department' and it wasn't functioning as a proper emergency department," Professor Goulston said.

Questions put to the Sydney West Area Health Service on Tuesday - including how it justifies keeping the emergency department open, whether patient transfers have been improved, what it was doing to increase consultant staffing levels, and what were the results of an audit on patient transfers - remained unanswered yesterday.


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