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‘Feel free to cope’ – this was the prevailing mantra, more years ago than I care to count, when I was a houseman in London and I was the last man on deck. I look back and shudder a little at times when I consider what coping looked like.
Of course, there is an appropriate time to knuckle down and ‘make it work, people’ as fashion guru Tim Gunn tells us. Yet, we have done ourselves little favour as a profession when coping in overstretched services veers into the near miss territory and, worse still, lapses into errors and never events.
In an era of financial stringency, we can end up treading a fine line between appropriate performance under pressure and crazy risk. I can personally recall an epiphany moment some years back when struggling to undertake surgery with no assistant. The scrub nurse did an admirable job but it was stressful. The outcome was happily satisfactory for the patient but, standing back from that moment, I realised that I had veered over an unmarked line. I vowed never again to put my peptic ulcer, my licence to practice nor, most importantly, a patient’s reasonable expectation of the care they would receive at risk.
Largely I’ve stuck to that. There are moments of extremis, out of hours, when it feels like too many plates are spinning at once, but for the most part I’ve learned to prioritise – some things simply have to wait.
Underlying this issue is the innate tension, in a limited resource system, between the beneficence we feel we owe a given patient at a given moment in time and the justice for all patients we also feel a burden to impart. Working that out day by day is a core skill of being a consultant in the Scottish NHS.
Compromise is an interesting concept: it’s a virtue and a slur at the same time. We see its virtue in the team finding ways to get on with the work, when numbers of junior medical staff dwindle, when we fail to recruit to a vacancy, when we try and maintain throughput with less and less staff. Yet that positive spirit of compromise is a micron away from a more negative idea, where we are compromising the quality and scope of care on offer.
Spotting that difference is an attribute that consultants are singularly equipped for in the clinical setting. Enabling and leading the positive is what we have done for years as vacancy numbers have climbed to nearly 10%. Avoiding the negative is the professional responsibility which now faces many of us in services where we simply lack any more ‘slack’. The threshold for ‘enough is enough’ will be different in each service, and its clearly felt earlier in smaller, or more remote settings, yet it is starting to bite across the nation.
BMA Scotland consultants committee has prepared measured guidance for services that are ‘on the edge’. Ideally, we would never get to this point, resilience planning would head it off, yet this is all too often not the case. It will therefore fall to us as leaders of services in Scotland’s hospitals to speak up when safety is at issue, both for ourselves and for the patients we serve.
Speaking up is not a comfortable thought. We hope we never to have to do so. If, reading this, you realise you’ve strayed across an unmarked line; I would encourage you to share your concerns with a colleague, to read our guidance, to seek support from your medical staff committee or LNC – to speak up. At the end of the day, this is about fulfilling our duties as a doctor. Nothing more but certainly nothing less.
Simon Barker is chair of BMA Scotland consultants committee
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