Pride and prejudice

This editorial marks the end of my term of office as Editor-in-Chief of Anaesthesia. Over the last six years, and for eight years before that as one of the Editors, I have had the privilege and pleasure of reading, assessing and publishing some of the best scientific and clinical insights to come from the minds and pens of medical researchers. A quick scan through the contents pages from 2004 reveals an eclectic mixture of areas of patient care and basic science where anaesthetists have made, and continue to make, their mark. In our own specialist fields, we have designed, developed and tested new technologies to improve safety and quality of care [1, 2]. We have become more adept at managing difficult, life-threatening airway problems [3, 4]. We have continually refined our practice to ensure that high-risk patients have a better chance of surviving major surgery [5]. We have been open and enquiring to new ways of working in multi-disciplinary partnerships [6, 7], and we have gone back to the laboratory to consider the basic building blocks of our science [8, 9]. We have fearlessly re-examined the sacred cows taught us by our predecessors, and discarded them where evidence is lacking or outcomes perverse [10–12]. Our long-standing commitment to patient safety, exemplified in recent years by the successful promotion and roll-out of lipid rescue for local anaesthetic toxicity [13], has even allowed the compilation of a virtual issue of the journal on the subject of ‘Safety and Human Factors’, with papers culled from the best that Anaesthesia has to offer. Deeper perusal of the pages of the journal show that it is not only in the field of anaesthetic practice that anaesthetists have been at the cutting edge of research and innovation. From critical care outreach [14] to trauma [15], from transplantation policy [16] to equipment design [17], from health service efficiency [18] to how best to train our future doctors [19], from epidemiology [20] to cost-effectiveness of novel therapies [21], and from ethical issues [22] to infection control [23], there are precious few areas within hospital medicine or the wider therapeutic community where anaesthetists do not play an active part in refining and improving the patient experience. I believe that there is a strong and cogent argument to be made that, at its best, anaesthesia more than any other specialty can represent the platonic ideal of the truly holistic doctor epitomised by John Snow, the earliest specialist in our art and voted as ‘greatest doctor ever’ by the readers of Hospital Doctor in 2003. Why, then, do anaesthetists occupy such a lamentably low position in the specialist hierarchy in the UK? For, as a result of the involvement with medical politics that inevitably accompanies editing the journal of the Association of Anaesthetists of Great Britain and Ireland (AAGBI), I am left in no doubt that we are, perhaps uniquely, poorly regarded by hospital management, central government, and, most galling of all, our medical peers. This is not just a personal view: evidence abounds. Much of what I am going on to recount is specific to the National Health Service (NHS), but overseas readers may well recognise similar features in the treatment of anaesthetists in their own countries. A reasonable starting point is the NHS contract. Renegotiated in recent years, the contract recognises two main components of a consultant’s workload, direct patient contact and supporting professional activity. The latter comprises time for management, teaching, audit, research and, critically, personal professional development in the form of continuing medical education. The new contract anticipated a ratio of direct to supporting professional activities for a typical consultant of 3:1, with a full-time job having 7.5 direct to 2.5 supporting professional activities. The NHS management have, to nobody’s great surprise, gradually whittled down what they regard as non-productive time so that many contracts are now offered at a ratio of nearer 4:1. This is bad enough, but at least all doctors are in the same boat. But, in September this year, I sat in the annual AAGBI Linkman meeting as one anaesthetist described how anaesthetic posts in her Trust were offered at a ratio of 8.5:1.5, while other specialty posts were allowed more time for supporting activities. The message? Anaesthetists do an easy job that is not intellectually demanding and therefore need less time to keep their skills up to the mark. Perhaps sadly, we live in a society where a person’s value is reflected in their pay, so this discussion of worth will have to encompass money. Here again, there is strong evidence of undervaluing of anaesthetists. Consultant pay within the NHS is fixed by national terms and conditions, and all specialists are – at least nominally – paid the same. But the government’s policy in recent years of reducing surgical waiting lists by farming procedures out to private hospitals (the so-called Independent Sector Treatment Centres) has loosened central control of pay. And what has happened? NHS surgeons are regularly offered considerably more money than NHS anaesthetists for working for the same period of time to treat NHS patients, the only difference being that these patients are not in an NHS hospital. The message? Anaesthetic care of a patient is worth less than surgical care, presumably because what we do is less critical, less skilful or requires less training. The link between worth and money is sometimes even more stark. The NHS rewards its top-performing consultants via a system administered by the Advisory Committee on Clinical ExcelAnaesthesia, 2009, 64, pages 1277–1282