Obstetricians on the labour ward: implications of medical staffing structures.

The 1981 Short report onmedical education in Britain recommended changes in the medical career structure.' Many other reports have addressed the fundamental problem associated with the traditional three tier structure of the consultant led team consisting of consultants, registrars, and house officers. In essence this problem arises from two conflicting requirements: the need to provide training in the context of a reasonable career structure while ensuring that patients are treated by fully qualified staff. From time to time targets for numbers of consultants and junior doctors designed to meet these conflicting needs have been set but never met, The inertia of the established organisation and practices and the resistance from those directly concerned have been too great to allow change. The Short report recommended an increase in the number of consultants and a reduction in the number of junior doctors in most hospitals and in most specialties; that the supply of senior registrars should keep pace with the increase in the number of consultants; and that all senior house officer posts should be frozen. In practice the Short report's recommendations have been interpreted to mean that in most district (non-teaching) hospitals medical staffing would be two tier and consultant based-that is, with only consultants and senior house officers. Registrars would be confined to specified training posts, usually in teaching hospitals. To permit such a pattern there would be a large increase in the number of consultants, who would share the routine work now generally carried out by registrars. In obstetrics this would include most forceps deliveries and caesarean sections. The proposed change from three tier consultant led to two tier consultant based staffing has been resisted by consultants, who are particularly opposed to reducing the number ofregistrars and senior house officers.2 3 Opposition has been strong among obstetricians, many ofwhom object to having to return to unsociable on call hours and night duty emergency work.4 We investigated the practical effects of the Short report's proposals for labour ward staff-doctors and midwives-and this paper concentrates on the implications for obstetric consultants. The important effects on junior doctors and midwives are dealt with in a paper yet to be published and in a detailed report of this research.5