From the editor

A bleak report with huge implications for hospital medicine

Not the Francis report, even though the words may equally apply, we refer to the RCP's report in March this year – The medical registrar: empowering the unsung heroes of medical care.¹ This carefully researched publication is based on the findings of the RCP's Medical Workforce Unit (MWU) – parts of which are published in this issue² and other parts will appear in future issues of Clinical Medicine.

The factors that need to be reconciled are clear. The number of fully trained physicians in various geographic regions of the UK correlates positively with good patient outcomes after admission to hospital. The number of consultants available is directly contingent on the number of doctors in training posts. The necessity to attract and retain high quality trainees in medical registrar posts, thereby providing a high standard of training, is therefore self-evident. What is also self-evident is that this process is under enormous strain. Indeed, the results of the 2012 second recruitment round for attracting specialist trainees at ST3 level – the stage of commitment to higher specialist training – make highly disturbing reading: ‘fill-rates’ were of the order of 60% overall for posts carrying a national training number and therefore starting the holder on the pathway to obtaining a Certificate of Completion of Training (CCT). In key specialties, notably acute internal medicine and geriatric medicine, the rates were far below that.

The work of the MWU documents the reasons. The duties of the medical registrar at the time of the acute intake have ‘just growed’ to a stage where nearly one-third of these registrars perceive that their workload is unmanageable when on call. And this is not a self-pitying response from the registrars themselves, but a judgement endorsed even more strikingly by their closest colleagues – those in core medical training (CMT) and foundation year (FY) posts. Furthermore, this is not a non-specific attribute of being a hospital registrar: judgements concerning the workload of surgical, anaesthetic and GP registrars are far less harsh.

The report describes and analyses the current role of medical registrars and the difficulties they face under seven headings: the specific role of the registrar, teamwork, workload, interactions with other teams and training – both as a trainee and as a trainer of more junior doctors. It documents the lack of clarity, the variation in the performance required and in the expectations of the registrars themselves. To take a single example – the ‘hospital at night’ team is described in some hospitals as creating a situation in which ‘the only person who is competent to do most of the work is the medical registrar’, yet in others as ‘leading to the medical registrar being undermined and disempowered’.

There is no single answer. Indeed the MWU report makes 41 recommendations in the full text and 18 in the executive summary. As an aside, one may reflect that major reviews tend to produce too many recommendations, and history condenses them dramatically. The 198 recommendations of the Bristol Heart Inquiry³ are contracted into putting the patient at the centre of everything. And the 48 recommendations of Dame Janet Smith's inquiry after Shipman⁴ come down to – in doctors’ minds at least – revalidation. At the time of writing we are still awaiting the government's response to the 290 recommendations of the second Francis report.⁵ But the major recommendation of the MWU needs addressing with huge urgency: it is that ‘Hospitals should undertake an urgent comparative review of the workload of medical registrars and their associated medical teams and modify workforce allocation as indicated’.¹ Being feted as an unsung hero is not likely to provide the sustained motivation to maintain a vital section of the hospital workforce – both for now and for the future – in a role that is so difficult to sustain.