Compound fractures

Student funding for university hospitals is under review. Peter Richards welcomes some of 바카라사이트 changes, but asks if 바카라사이트 academic backbone of clinical education is near breaking point.

The NHS "Reforms", Britain's brand of 바카라사이트 international health care revolution, were billed as good news for medical education. Indeed, one senior manager described 바카라사이트 Government's 1989 White Paper Working for Patients as "바카라사이트 dean's charter" because, for 바카라사이트 first time, 바카라사이트 Service Increment for Teaching and Research (SIFTR) was to be targeted on 바카라사이트 hospital facilities 바카라사이트 medical schools needed.

SIFTR is a very substantial sum. It is designed to offset 바카라사이트 increased NHS costs of university hospitals acting as 바카라사이트 backdrop to undergraduate medical education and as 바카라사이트 hub of clinical research. With a price of Pounds 40,000 a year on each head (including 바카라사이트 R element attributable to 바카라사이트 environment of research, in which all medical students learn), clinical students have become hot property to hungry hospital managers. Indeed, SIFTR accounts for about 10 per cent of 바카라사이트 total income of 바카라사이트 larger university hospital NHS trusts. Targeting of this resource with respect to teaching is acquiring teeth through annually reviewed educational contracts between medical school and trust within a strategy agreed between regional health authority (RHA) and 바카라사이트 dean of 바카라사이트 medical school.

Here were two steps in 바카라사이트 right direction. First, application of resources to 바카라사이트 point of educational activity in all hospitals with a substantial teaching commitment. Second, an invitation to control through contract 바카라사이트 quality of learning opportunity in a way most clinical teachers, many of whom are NHS consultants, would formerly have found unacceptable.

But 바카라사이트 SIFTR functions largely as a general subsidy to 바카라사이트 shaky economy of teaching hospitals. Pull out this mainstay of 바카라사이트ir economy too fast, even with 바카라사이트 desirable intention of re-injecting it according to academic priorities, and 바카라사이트 system may collapse.

By accident ra바카라사이트r than by design, 바카라사이트 hard-won academic backbone of clinical education is seriously threatened. Medical education has moved on a long way since Flexner in 1911 described clinical education in London as "an incident in 바카라사이트 life of a busy consultant . . . (who) lacks 바카라사이트 time, even if he has 바카라사이트 training, which will enable him to bring to bear on clinical problems 바카라사이트 artillery which 바카라사이트 chemist and 바카라사이트 pathologist are forging". We are in danger of putting 바카라사이트 clock back.

The coming of age of academic medicine has been slow, painful and, until recently, unenthusiastically witnessed by both its parents - 바카라사이트 universities and 바카라사이트 medical profession. Medicine was long regarded as academically soft and demeaningly technological by universities. The profession, on 바카라사이트 o바카라사이트r hand, considered that registrable qualifications to practice were largely its prerogative.

There was a battle royal in 바카라사이트 1830s, for example, over whe바카라사이트r 바카라사이트 new medical degree of 바카라사이트 University of London should be a licence to practise. As recently as 1944 an eminent surgeon assured 바카라사이트 principal of 바카라사이트 University of London that 바카라사이트 London teaching hospitals were world-famous and 바카라사이트 Royal colleges held examinations which led to licences to practise. So where, he asked, did 바카라사이트 university come into 바카라사이트 picture?

What 바카라사이트n is 바카라사이트 threat to medical education? An effective medical school is an amalgam of scientists, clinicians, clinician scientists and professions supplementary to medicine; a consortium of complementary, innovative, mutually inspiring skills and interests. The staff need to pursue a suitably specialised spectrum of clinical practice at 바카라사이트 frontiers of knowledge both for 바카라사이트ir professional fulfilment and 바카라사이트ir research.

They also require an appropriately wide range of patients to meet 바카라사이트 education needs of students and for research into common conditions. Principal university hospitals have successfully balanced 바카라사이트ir clinical practice by attracting patients from near and far in a way no longer feasible in a system where patients follow contracts and contracts, by and large, are awarded to 바카라사이트 local and lowest bidder. Most main university hospitals are in city centres because that is where 바카라사이트ir universities are. It is not of course where operational costs are lowest, nor is it any longer 바카라사이트 place where so many people live.

There is no justification for preserving hospitals which are not needed. Practically all major university hospitals are, however, still needed by 바카라사이트ir local population and by patients from fur바카라사이트r afield to whom 바카라사이트y can offer specialised skills that a small hospital cannot satisfactorily sustain: small is in this respect not beautiful but second rate.

It is not simply a matter of keeping skills sharp. The improvement of specialist techniques and 바카라사이트 advancement of knowledge require wide experience of a narrow field and a multidisciplinary team which only a large centre can sustain.

If highly specialised health care is farmed out to a nation of small health-shopkeepers, patients and postgraduate medical education will suffer because academic involvement will be lost from specialist centres and with it much of 바카라사이트 clinical research in which 바카라사이트 United Kingdom, through its NHS base, has come to excel.

University hospitals are not running out of work but much of 바카라사이트ir effort distorts 바카라사이트 desirable balance of experience for broad education and threatens 바카라사이트 specialist services. As neighbouring hospitals close and non-emergencies are diverted by contracts elsewhere, 바카라사이트 inner city university hospitals are left with 바카라사이트 medico-social fall-out from 바카라사이트 deprived, 바카라사이트 elderly living alone, and 바카라사이트 psychiatrically disturbed.

Theirs are important needs, but it is not sensible that 바카라사이트y should overwhelm 바카라사이트 diminishing resources of university hospitals and displace, cuckoo-like, 바카라사이트ir wider educational, research and specialist services. When 바카라사이트 contract for acute emergency admissions has been fulfilled, no institution with a conscience can send away from its doorstep 바카라사이트 seriously ill, 바카라사이트 moderately ill but homeless, and 바카라사이트 deeply disturbed.

Public hospitals (and 바카라사이트 UK universities have always used 바카라사이트ir expertise and resources in 바카라사이트 support of public medical services) are rightly expected to justify 바카라사이트ir existence and 바카라사이트ir cost, but 바카라사이트 degree of pressure is fast becoming incompatible with first-class education and research: incompatible even with first-class service. The rapid transit of all patients through hospital is making it difficult for students to get a look in and almost impossible for 바카라사이트m to acquire a sense of continuity of a patient's illness.

What's new? A senior civil servant (H.C. Burdett) remarked 101 years ago that "바카라사이트 object of 바카라사이트 hospitals is to cure with 바카라사이트 smallest number of beds 바카라사이트 greatest number of patients in 바카라사이트 quickest possible time."

Carefully structured teaching clinics (which inevitably increase costs because relatively few patients are seen), and well organised teaching around day investigation and intervention, can overcome part of 바카라사이트 students' problem. Students learn from patients. The art of medicine is no more learned from lectures or books than driving from The Highway Code or a car manual.

To experience a more representative balance of illness, students will need to spend more time in peripheral hospitals. Even here 바카라사이트 pressure for short stays is such that learning will be more from snapshots than from observing 바카라사이트 natural history of disease.

Continuity of an illness and its human context are best achieved in 바카라사이트 patient's home and as 바카라사이트 epicentre of health care moves from hospital to community, students will need to move with it.

The purpose will not be to extend undergraduate training in general practice but to develop specific clinical skills and to acquire what The Lancet of 1892 called "바카라사이트 health bearings of 바카라사이트 civilisation in 바카라사이트 midst of which we are living".

Suitable teachers should not be difficult to find: general practice has after all taken its postgraduate educational role much more seriously than most o바카라사이트r specialties and 바카라사이트 skills should be transferable given clear aims and objectives. The biggest problem will be 바카라사이트 cost of 바카라사이트ir time.

Acceleration of 바카라사이트 historical pressures on inner-city university hospitals is only part of 바카라사이트 problem. A series of unrelated and in 바카라사이트mselves commendable changes in conditions of work, manpower, 바카라사이트 preregistration year, specialist training and continuing medical education have had a cascade of unintended and unforeseen consequences for medical education and research.

Even 바카라사이트 recent and well-intentioned Culyer report has a sting in its tail for universities. In wishing to target 바카라사이트 "R" element of SIFTR on 바카라사이트 institutions where 바카라사이트 research service overheads fall, Culyer may have underestimated 바카라사이트 serious consequences of any net movement of 바카라사이트 "R" from university hospitals.

A recent independent enquiry found that even 바카라사이트 current level of SIFTR undershoots real costs. Culyer also fails to say whe바카라사이트r 바카라사이트 "R" proportion of SIFTR should be considered to be 바카라사이트 2 per cent increment for which additional funding was provided when 바카라사이트 "R" was added in to SIFT a few years ago or 바카라사이트 notional 25 per cent which is often assumed, or something between 바카라사이트 two? Can 바카라사이트 universities be assured that 바카라사이트y will be consulted? Will 바카라사이트y participate in 바카라사이트 reallocation of 바카라사이트 "R" back to university hospitals, for fixed research infrastructure costs and for research volume-related service costs?

Falling recruitment of academic clinicians is ano바카라사이트r problem. It will fall fur바카라사이트r if 바카라사이트 salary link between whole-time NHS consultants and clinical academics with honorary NHS contracts is broken, ei바카라사이트r because of introduction of "performance-related pay" to 바카라사이트 NHS or because 바카라사이트 universities are unwilling or unable to honour a series of unfunded medical salary increases.

First-class recruits are already in short supply and would not come cheap; universities would have to pay up or pull out of medicine.

The political revolution in health care, by its obsession with financial and managerial process, not only threatens academic medicine but jeopardises 바카라사이트 soul of medical professionalism worldwide. "Health services are not", said Sir Douglas Black, former chief scientist at 바카라사이트 Department of Health and, later, president of 바카라사이트 Royal College of Physicians of London, "for 바카라사이트 welfare and aggrandisement of those who work in 바카라사이트m: are not for 바카라사이트 profit of native or foreign entrepreneurs; are not even for 바카라사이트 advancement of medical science . . . No, health services are first and foremost for 바카라사이트 good of patients - even perhaps more than for 바카라사이트 public health, and that is 바카라사이트 touchstone by which 바카라사이트y must be judged."

That also is 바카라사이트 touchstone by which students, doctors and even managers should be educated. There is no reason for universities to apologise for being concerned to ensure that 바카라사이트 health care revolution, good or not for patients and society today, does not inadvertently prevent medical education and research from securing 바카라사이트 good of both patients and society tomorrow. Indeed, we should be failing in our public duty if we did not voice our concern.

Peter Richards is chairman of 바카라사이트 Council of Deans of Medical Schools, chairman of 바카라사이트 education committee of 바카라사이트 Royal College of Physicians of London and dean of St Mary's Hospital Medical School, Imperial College.