Be assured of your RMO

Private hospital reliance on the Resident Medical Officer (RMO) system has come under attack from an independent, non-party think-tank. Dr Stephen Drotske and Justyn Tollyfield hit back fighting.

In November 2017, the Centre for Health and the Public Interest (CHPI) published a report entitled ‘No safety without liability – reforming private hospitals in England after the Ian Paterson scandal’.

The report used data from Care Quality Commission inspections at several private hospitals to set out five key recommendations designed to increase standards and, above all, patient safety within the sector.

In this article, we aim to address the third key recommendation, specifically the assertions that:

1. RMOs should be employed by hospitals directly rather than by outside agencies;
2. One RMO should not be required to look after a significant number of beds;
3. Reliance on doctors trained outside the UK presents a risk to patient safety.

Our company, NES Healthcare, is the UK’s largest supplier of RMO services, currently employing more than 500 doctors within both private and NHS hospitals. So it could be argued that we have a vested interest in maintaining current RMO practices.

But, despite this, we do recognise there are areas, including some identified within the CHPI report, where improvements could and should be looked at.

After all, since 1994, NES has been the driving force for significant changes to the conditions and professional standards for RMOs.

We would therefore like to present a balanced response to recommendation three from the CHPI report, which reinforces some elements, yet challenges those that we feel are based on misconceptions.

1 Reliance on outside agencies

A key CHPI criticism of the current system relates to the model whereby private hospitals use companies such as ours to provide their RMOs.

It argued that they should employ the doctors themselves.

The rationale for this argument is broadly that devolving the responsibility for the appropriate management and governance of these doctors allows hospitals to avoid liability and therefore presents an unacceptable risk.

What the report does not cover in detail is what this risk is. Instead, it cites a small number of examples, such as one case where a doctor – not ours – had not been subject to ‘the relevant and legally required background checks’.

While this was a clear breach of an employment company’s responsibilities, one such case does not necessarily mean all companies are prone to similar lapses.

As a provider of RMO services, we are responsible for doing all necessary background checks, specifically references, qualifications, criminal records and occupational health.

We also ensure completion of mandatory training, a medical English exam and the essential qualifications from the UK Resus­citation Council that ensure a doctor can lead a resuscitation team.

Full liability

As the employer, we accept full responsibility and liability for the actions of our doctors, including professional indemnity provision.

We are subject to regular audit and inspection by the relevant authorities and have a track record of consistently achieving outstanding levels of compliance. Our credibility, and therefore our business, depends upon us providing a safe and reliable model for our clients and, by extension, the patients.

On average, we engage 30 new doctors each month, so we have invested to create an appropriate infrastructure, both in terms of facilities and staffing to ensure this is done to the highest possible standards.

If one solution to eliminate a perceived risk is for hospitals to employ doctors directly, does that mean it is necessarily the right one? The hospital in question would be infrequently recruiting a small number of doctors on an ad hoc basis.

Is this a better arrangement than using a specialist organisation that does this on a far larger scale?

What happens when the duty doctor is sick or unable to work for any other reason, such as a family emergency? In a direct-employment scenario, the obvious response would be for the hospital to turn to a locum agency to provide short-term cover, but this introduces a whole new level of risk around availability, suitability and a significant cost increase.

Standby doctors

NES deals with such situations every day and has a team of standby doctors available all over the UK to respond at a moment’s notice. All of them have been recruited to the same high standards in terms of professional competence, language ability and background checks.

The report suggests that supervision for RMOs is ‘apt to be weak’, referencing cases where a lack of clarity existed in respect of clinical supervision. This highlights the need for a clearly-defined system.

Junior doctors in the NHS are supervised by consultants as part of their training programme. The limitations created by the structure of the private sector, including the role of the consultants and the lack of a training element within the RMO role, make this more of a challenge.

This makes it even more important that companies like ours have clear structures in place so that performance is managed and responsibilities relating to clinical supervision are clearly delineated.

Our clinical team, under the guidance of a medical director and Responsible Officer, is the first point of contact for any concerns relating to a doctor’s scope of practice.

Clinical mentorship for doctors while at a hospital is frequently provided by a designated consultant. This system provides clarity and support for the individual doctors.

2 Bed numbers

‘The errors that occur in healthcare are rarely the fault of individuals but are usually the result of problems with the systems they work in,’ admits NHS England in its ‘About Patient Safety’ web pages.

The CHPI report quotes research by Prof Brian Jarman of Imperial College that ‘there is a strong correlation between the number of doctors employed for each bed in a hospital and the number of deaths in that hospital’.

But this research focused on the NHS and with no data to support the same outcomes in the private sector, these assumptions are open to challenge.

It is not uncommon within a private hospital for a single RMO to be on duty, irrespective of the number of inpatient beds available for occupation.

On top of their routine duties, they play an important role in responding to emergencies.

If the number of beds is excessive, and indeed the report cites the case of one RMO looking after 96, then common sense dictates that this doctor may struggle to maintain an effective level of patient care for all.

At first glance, to better the system and to match the research, it would therefore seem that a cap should be placed on the number of beds that a single doctor can be responsible for looking after.

This, however, may be a simplistic approach that does not take account of a private hospital’s patient acuity, bed turnover and hospital staffing.

Our approach is to closely monitor the workload that our doctors face at our client hospitals and, where necessary, to make recommendations to hospital management around either the need for additional manpower or a change to the rotation structure.

3 Overseas doctors

One of our overriding criticisms of some sections of the CHPI report is that they are written from a viewpoint that seems to take no account of the challenges and realities faced by the healthcare sector as a whole.

Changes are recommended, yet there is a distinct lack of concrete proposals as to how these might be achieved.

One example of this is the section where it criticises the ‘reliance on doctors trained outside the UK to fulfil the RMO role’.

The reasons for highlighting this as a risk appear to be around the lack of familiarity with the UK health system and issues around English language, as referenced in the case of one doctor struggling with communication after working for just three weeks in the UK – again, not ours.

The private hospital RMO role has never been of any particular interest to a UK-trained doctor or one with extensive working experience gained within the NHS. This is mainly because the role will not form part of their training and does not therefore contribute towards their career aspirations. It is also not typically as challenging or clinically stimulating as some alternatives.

In over 20 years of recruiting RMOs for hospitals in the UK, we have received applications from only a handful of UK-trained doctors. Only a fraction of these went on to start work with us.

It cannot be ignored that there is a national shortage of doctors across all areas, both geographically and by specialisation, across the UK. This is only going to worsen as Brexit approaches.

Already we have observed an increasing reticence from Euro­pean doctors to take up positions in the UK, and a BMA survey of 1,720 doctors in November 2017 found:

 More than nearly half (45%) of doctors from the European Economic Area (EEA) surveyed are considering leaving the UK following the referendum vote. This compares to 42% of EEA doctors surveyed in February 2017;

 Of those considering leaving, over a third (39%) have made plans to leave, meaning almost one-in-five EU doctors (18%) have made plans to leave the UK.

The UK has relied upon overseas doctors since the NHS’s creation in 1948. Another GMC report in 2017 found that nearly half of the doctors working within the NHS were trained overseas.

Foreign doctors are essential to the UK healthcare system. What is also clearly essential is that their introduction here needs managing effectively and in such a way as to minimise any risk to patients during the early days of their work. This is where companies like us can make such a sizeable contribution.

For example, we have learned that it can take anything between six months and two years to recruit a doctor.

Throughout this time, we assure ourselves that they have the knowledge and experience commensurate to the role they are being considered for.

We require them to practise the skills they will be using once they are in the UK. We take them through training programmes that are all based around the skills and protocols associated with UK healthcare.

Once a doctor arrives in the UK, they are assessed again in person, covering language, clinical skills and pharmaceutical knowledge. They then spend an appropriate period on site at their designated hospital, learning the role under the supervision of an experienced colleague.

Closely monitored

Thereafter, their work is closely monitored both by NES and hospital staff, with feedback sought regularly. These doctors are immediately added to our Designated Body list and will begin gathering evidence for their first appraisal.

We have followed this process for over 700 new doctors in the last five years alone. Most of these individuals have completed fixed-term contracts with us and gone on to establish themselves in NHS training posts or other training programmes. So we play an invaluable, and entirely unrewarded, service in NHS recruitment.

This is all very well, you may ask, but what are the outcomes?

The CHPI report notes that ‘doctors trained outside the UK have double the rate of fitness-to-practice sanctions against them compared to UK-trained graduates’.

Reviewing RMOs’ success in the private sector reveals low levels of complaints over consecutive years. During the last five years, no doctor employed by us received GMC disciplinary sanctions and we currently have zero open cases at the regulator. Comparing this with any NHS trust of similar size shows these statistics are an accolade.

NES has experienced a continual improvement in quality standards and a reduction in levels of complaints at the same time as seeing a significant increase in accolades, which doctors will use as part of their medical appraisal. This is the result of the hard work we put into recruiting the right people and making sure they are fully prepared.

Conclusion

There is far more in the CHPI report with which to agree than to disagree. Here we have simply focused on the third recommendation, as this is where we feel we are most qualified to comment.

But it is our belief that, in this area, the report has identified risks of third-party involvement without properly assessing these third parties.

There is also an assumption that direct hospital employment of doctors would solve some of the issues the report identified.

Yes, we agree there is a case for many private hospitals to review their RMO requirements, either in terms of numbers or rotation pattern, especially if one doctor is routinely responsible for a large number of beds.

What is difficult to support, however, is the contention that the use of overseas doctors poses an unacceptable risk to patients in the UK.

These skilled immigrants are a fundamental part of our health system and, if they are recruited and introduced safely by well-regulated and competent companies, they will go on to make a massive and safe contribution to the UK health system.

Dr Stephen Drotske (left) is the medical director and Responsible Officer, and Justyn Tollyfield (right) is operations director at NES Healthcare