Now, where are those matches at the end of this tunnel?
Editor – 20 years ago, pretty much to the day, Professor JR Bennett wrote ‘will the last one out please turn off the lights in the emergency admissions ward’.1 I fear Paul Jenkins’ matches are far too little and much too late.2 And, anyway, we are nowhere near the end of the tunnel.
Professor Bennett is the Cassandra of this tale. His editorial, ‘The general physician – dinosaur or superman?’, pretty much predicted all that has come to pass.
The catastrophe that is acute general medicine is a consequence of the syzygy of four separate, not altogether unconnected, events. I will describe the Norwich experience – Dr Jenkins hails from Norwich – although I know this has been replicated in teaching hospitals across England. It is worth pointing out that district general hospitals (DGHs) have weathered the storm far better as they do not have the luxury of multiple belligerent specialists to shoe-horn into creaking general internal medicine (GIM) rotas.
First came the closure of rehabilitation/convalescent hospitals. In Norwich, the canary in the coal mine was the sudden appearance of a flock of geriatric colleagues in the acute hospital offering to take over the care of elderly GIM patients. Slightly baffled, we specialist physicians seized the opportunity at face value. Only subsequently did we realise that the geriatricians had been rendered cageless as Norwich lost all of its community beds.
Secondly, the Royal College of Physicians promised a new specialty to deliver acute medicine. Acute medicine, as part of the Acute Care Common Stem, is a necessary service; just not in its current incarnation. The trust was persuaded that this new specialty would assume responsibility not only for acute admissions – the ‘front door’ – but ultimately for GIM in its entirety.
Thirdly, specialists seized the opportunity to make an unseemly dash to specialisation and super-specialisation. Professor Bennett has pointed out the Kafkaesque disincentive in which training for ‘generalists’ is a year longer than for ‘specialists’, the rewards for which are: a delay in achieving certificate of completion of training; being forced onto GIM rotas; having a reduced exposure to specialty patients; and to earn the public's opprobrium – despite having identical specialist training to the ‘specialist’. Cardiology were first out of the blocks and were immediately followed by respiratory medicine. Gastroenterology's solution was to arrange regional rotations such that their specialty registrars did their GIM training in regional DGHs and their specialist gastroenterology training in Norwich; thus, the gastroenterologists were lost to GIM services in Norwich. The last doctors standing – nephrology and endocrinology – looked over our shoulders to find that everyone else had taken two steps back and we had been volunteered to manage the hippogriff. I advised at the time that this flight from GIM would mean running out of the doctors to deliver it within 10 years. We did.
The final straw has been the King's Fund proposal – inimical to the interests of acute hospitals – to combine the health and social care budgets. This combination has happened de jure in Greater Manchester but is happening de facto across the country as community services achieve the budgetary event horizon and completely collapse. Some years ago, I trawled the medical wards and advised this trust that there were at least four wards of medically fit ‘patients’ waiting for a discharge destination. These 150-plus ‘patients’ entirely explained – and explain – our perpetual bed occupancy of >100% (patients sitting out the night on the dialysis ward for example), our cancelled surgical lists, our accident and emergency breaches, our nursing and medical staff shortfall, and our financial predicament.
I am delighted that former poachers are looking to become gamekeepers. It is essential that they learn the lessons from history and they should start by reading Professor Bennett’s editorial.
Conflicts of interest
The author has no conflicts of interest to declare.
- © Royal College of Physicians 2017. All rights reserved.
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