So this [1] happened. The petition of over 220,000 signatures to debate a vote of no confidence in Jeremy Hunt was commuted to a Westminster Hall debate on the nebulous subject of ‘contracts and conditions’ within the NHS. It’s concerning in this day and age how ill informed policy makers are on subjects with huge implications- literally life and death. As a doctor brought up in the evidence-is-king era it is hard to listen to anyone who makes decisions based on anecdote or ideology that have such a large impact. Let’s look at what was actually said.

---

Helen Jones, Warrington North MP for Labour- opens by explaining the committee doesn’t have the power to debate a vote of no confidence, so the issue is sidestepped to discuss conditions and contracts of NHS staff. She discusses staff demoralisation and then mentions there is a £1 billion NHS trust deficit this year. She also goes on to mention the £20 billion savings required from the last parliament and this is ‘due to rise to £30 billion by the end of this parliament’.

These numbers are confusing to say the least, and in fact several MPs in this debate mix them up without correction from the others.
They come from here [2] the ‘Five year Forward’ plan from NHS England- the commissioning and business public body quite separate from individual trusts. The actual figure is a predicted demand – resources mismatch of £30 billion/year by 2020. That means over the next five years the NHS, at current level of demand, funding and efficiencies, will be progressively underfunded year on year by an exponential amount up to £30 billion in 2020 ALONE. If someone could do an area under the curve analysis here that would be greatly appreciated but I estimate that to be around £50-60 billion over five years. NHS England suggested three scenarios to meet this demand, built on increasing efficiency targets to meet either a third, a half or all of that target. In essence it’s suggesting that the NHS finds all of this missing £50-60 billion in efficiency savings, or funding needs to increase to match a half or two-thirds of the yearly deficit.
The government line on this, deliberately obtuse, is to pledge an additional £8 billion to the NHS. Every news outlet seemed to confuse the figure and the amount- is it per year or over parliament as a five year time period. Here is an excellent article detailing the confusion; [3] but it seems obvious that Hunt doesn’t understand and Osbourne and Cameron are talking about over five years, not per year as per many newspapers. This is a direct quote from the manifesto.

‘Because of our long-term economic plan, we are able to commit to increasing NHS spending in England in real terms by a minimum of £8 billion over the next five years.’

Additionally there has been no £8 billion increase in the 2015 budget at least.
So to summarise this point- NHS England and a number of analysts predict the annual deficit of NHS funding to be £30 billion/year by 2020. The government has proposed to give £8 billion, or £1.6 billion a year, to help this problem. This means even with the proposed £22 billion of efficiency savings*, which are very likely unreachable, the system will remain underfunded , rising to an average £6.4 billion short by 2020. More probably this figure will be around £15-20 billion as trusts struggle to squeeze their already stretched resources any further.

---

Let’s continue.

Helen Jones goes on to state the government cut nurse training places by 3000/ year in 2010. Yes [4] this did happen. Training places are only now returning to previous levels.
She goes on to mention the 1% pay freeze, an effective paycut, and its effect on incremental pay over this period. Then a few other MPs try to butt it in for a bit**. She notes as a consequence of a lack of nurses agencies are making a lot of profit.

Then Helen Whateley, Faversham and Mid Kent, Conservatives brings up the figure of a 2.1% increase in nurses, midwives and health visitors between 2010 and 2015- an additional 6622 staff.
The government loves to lump nurses, midwives and health visitors into a single statistic, even though this is ridiculous as all three do jobs that are usually poles apart from one another and address completely different aspects of the system. The official figures are here [5].
Qualified nurses (excluding GP nurses) –

2014 -313,514 vs 2010 – 309,136 FTE

(1.3% increase or 4378)
-which includes all of the below:
Midwives; 21,670 vs 20,790 ( or 880 increase)
Health visitors: 12,100 vs 8,017 (50% increase or 4083)
So the reason Helen Whateley, Faversham and Mid Kent, Conservatives likes to bring up this figure is community health visitor numbers have increased but the rest of qualified nursing has remained static – if you look at full time equivalent cover in hospitals which is what this debate is about. I find it a little disingenuous to throw this figure into a debate about nursing cuts.

And Helen Jones rightly corrects her.

---

Helen Jones returns to state we are short of GPs, especially in areas such as Warrington, as previous stated in PMQs in 2014 [6]. She states some areas will need 50% more GPs by 2020.

Those figures come the RCGP- here is the original press release. [7] There are some areas in this report that estimate will require up to 70-80% more GPs (Bexley, Redbridge and Swale) and overall a requirement for 8000 more GPs to cope with demand by 2020. As an aside the NHS spends just under 9% of it’s budget on GPs,which may fall to 7.2% by 2017 [8] and this is where 90% of all contact with services occurs.

The cost of opening at weekends and evenings is then brought up at £749 million for 1 in 4 surgeries and £1.2 billion for 1 in 2. These figures are attributed to RCGP research [8] from 2014- I cannot however work out how these particular numbers were extrapolated. Another source, Dr Mortons, put out similar numbers, but given that is a private GP out of hours advice helpline it is not a greatly unbiased source and I couldn’t find the original report. The government has pledged £150 million to make this happen- again, if the estimates are accurate, this doesn’t really touch the sides.

Helen Jones rightly mentions that the ‘opt out’ clause Jeremy Hunt has referred to as a barrier to emergency work refers to 0.3% of elective work. This is all well detailed here [9].

So far, good work Helen Jones.

---

Then we get into the Freemantle paper recently released by the BMJ.

Dr Sarah Wollaston (Totnes) (Con) brings it forward and then both sides misconstrue certain elements.

Let’s go through the paper in question.
– The paper is an update from a previous Freemantle paper that was presumed to be the source of the initial Hunt claims . The update was at the behest of Professor Bruce Keogh, presumably by the government.
-The original paper is analysed here [10] and the update has the same general conclusions;
– the conclusions are similar as before- the event ratio of death for patients admitted on the weekend is higher than the ratio of death for patients admitted on the weekday.
– the emergency case mix on the weekends is 65% on a Sunday vs 30% on weekdays
– sickness was measured by the Charleston Comorbidity Index- this is a multi point scale that details many conditions- vascular disease, diabetes etc. Many of which would not be on a discharge summary routinely – therefore would not make it into this analysis anyway.
– the ‘adjustment’ for sickness in this case was to remove those that died within three days and retest the analysis
– median length of survival for weekend admission patients that died was nine days and eight days for those that survived
– in the previous paper 94% of deaths occurred in those admitted as emergencies
– all of this data comes from clinical coding which is done by specialist clerical staff from discharge summaries and death certificates written mostly by junior doctors.

Now work this through carefully. No matter your patient cohort (age, comorbidity, condition) you are 20x more likely to die (based on the previous emergency/elective admission death ratio from the 2012 paper) if you are admitted as an emergency than as an elective admission – and this needs no explanation.
If you admit 1000 patients Monday to Friday and 100 patients Saturday to Sunday with the above case mix difference- 350 emergencies come in Monday to Friday and 65 come in Saturday and Sunday. For arguments sake let’s say each emergency has a 20% chance of death and each elective admission a 1% chance of death to make a nice easy to understand figure.
Over this imaginary week you will have 70 (20% of 350) emergency deaths for patients admitted Monday to Friday and 6.5 (1% of 650) elective deaths. There would be 13 (20% of 65) and <1 elective (1% of 35) deaths on Saturday and Sunday. If you stopped there with the absolute numbers you could say hurrah! Weekends are safe! But that doesn’t take into account the admission numbers- you need to generate an event rate to get mortality.
So we then take 76.5/1000 = 7.65% and 13.3/100 = 13.3% and we say oh no! Look at how unsafe the weekends are! Completely ignoring the fact we diluted the ‘mortality’ rate by padding the weekdays with healthy elective cases and the risk of death remains the same.
So now we should look again and compare emergency admissions with emergency mortality rates: this would be sensible. This analysis is missing from the updated paper- and is present in the original but the raw data is not provided to show if this ‘rate’ is balanced against all admissions or simply emergency admissions. ***
– the other key point about this paper is that it doesn’t make sense on an actual practical level. Hospital deaths are pretty rare – in the paper the overall rate was 1.8%. These deaths occur on average a week after admission – when they have already had 5-7 days of inpatient care under all the team. If you are actually in hospital at the weekend when staffing issues are apparently detrimental- your chance of dying is 20% LESS. So the suggestion these admissions do worse because of hospital weekend resources is ridiculous. The paper acknowledges the vastly increased proportion of patients in the sickest top two categories, and corrects for this by reanalysing the data minus deaths in the first three days and ‘correcting’ for the predicted mortality at 30 days of these patients. But this neglects the fact the vast majority of these deaths were emergency admissions- no matter how unwell the patients are as a background ( using their co-morbidity index) an acute illness is always a worse prognosis than a chronic condition if you look over 30 days only.
– ultimately this paper is not useful for making any real life decisions- the data collection is artificial and relies on coded outcomes from discharge summaries, the analysis is unclear where the data and the rates arise from and the conclusions seems awfully skewed towards suggesting seven day working patterns are a causative problem.

---

So back to the debate.

Helen Jones makes an accurate point with the case mix and Maria Caulfield is also right that patients may not have had access to their GP- or more likely did not want to navigate out of hours and rather plumped for hospital admission instead, selecting out a sicker cohort of patients who couldn’t attend OOH services.
Helen Jones goes on to make some good points – junior doctor salaries start at a basic rate of£22,636 and the new contract now being imposed without negotiation will be an effective paycut of 16%-30%. Here are the numbers [11].

---

Then Dr Sarah Wallaston Totnes Cons speaks. Her opening remarks to say her forensic psychiatrist husband already works weekends are a little confusing- is she suggesting that’s what this debate is about?
– She goes on to discuss the Freemantle paper and attributes the plans for seven day working to the results- which as above is not appropriate

---

Paul Flynn Newport Labour MP- makes a good point about the petition being apolitical- this goes someway to shutting down the conservative MPs who don’t want to make the NHS about political point scoring.

Helen Whateley then gets up to try and score some political points. She first tries to take credit for the NHS confidence improving under Conservatives- these are annual Kings Fund NHS survey of the public figures which actually were at an all time high in 2009 at 70% reporting being ‘very satisfied overall’ [12] and then after the release of the Mid Staffordshire report and a year of bashing the NHS in the media in the run up to the Health and Social care act the repeat survey dropped to 60%- this has been slowly recovering and reached 65% in 2014.

She then implies the Freemantle paper is beyond reproach in its insinuations- which is far from the case.
She mentions the ‘extra’ £8 billion funding again- despite NHS funding is actually falling as % GDP every year- and as above still dramatically underfunded. In fact the NHS budget has risen the least year on year in the decade so far since its creation in 1948.

---

She claims the Secretary of State has been rolling up his sleeves and ‘not just listening to the sound of bedpans but emptying them’.
Let’s take a moment to reflect on the man chosen to be health secretary.

1) He co-authored a book called ‘Direct Democracy’ which explicitly idealises the dismantling of the NHS and how to do it [25]
2) In 2012 he was stepped down from the position of Culture secretary following accusations of corruption over the BSkyB deal- ie putting private interests first over public benefit.
3) He has no medical or scientific qualifications- he has a 1st PPE from Oxford.
4) His background is business- he ran an unsuccessful marmalade export business for a while.
5) His predecessor Andrew Lansley was funded by Care UK- a huge private health insurance company.
6) It is an instant dismissal offence to break patient confidentiality. The DoH found a picture taken on Mr Hunts phone and shared to 70,000 people was an ‘innocent mistake’. Still no one has apologised to the named patients on that list, telling the whole world about their medical histories without their consent.

I think he likes bedpans so much because he is so au fait with b******t.

---

She then goes on to state that 70% GPs found their CQC inspection helped reflect upon improvement. This figure comes from the CQC and isn’t available on their feedback and surveys website as yet. However this GPonline figure with the CQC quote conducted its own survey; 62% of GPs surgery rated the CQC inspections as ‘inadequate’ or ‘needs improvement’. [13]

Helen Whateley then goes on to state ; a large proportion of the NHS is very supportive of him. I cannot find any evidence of this. Please let me know if you are an NHS professional that supports Jeremy Hunt.

---

Paul Scully (Sutton and Cheam) Cons: brings up the Commonwealth report [14] from 2014 to suggest the NHS is improving globally under the Conservatives. This is a U.S. Study and is mostly built on data from 2011-12 with a smattering of outcomes recorded in 2013. The Health and Social Care Act was passed in 2012- so most changes we are now seeing are not recorded in this window. Interestingly this report also shows the UK spends the least on healthcare as a % GDP than any other country bar New Zealand. But this isn’t mentioned.

He also responds to a question regarding the £5 million pound programme from Simon Stevens plan to start Zumba classes and other work based moral boosters to prevent the £2.4 billion annual cost of sick leave amongst NHS staff. That seems a very little amount for such a vast problem.

---

Jo Churchill (Bury St Edmunds) (Con):

Speaks rather vaguely then states it takes five years to train a GP. She then states that heart attacks and children with broken bones get a worse service at weekends, despite both falling into emergency care and not related to the opt out negotiation.
She then emplores we consider the ‘back door’ and discharging patients on weekends too.
When challenged about discharge difficulties with a stripped social care budget she answers vaguely ‘it’s a mixed picture’ and then ‘looks to the leadership’ – like to the heavens, for divine inspiration.
She then says 3 million NHS staff is 1/10th of the population (it’s <1/20) and that the petition is ‘neither constructive or helpful’. How endlessly patronising to 220,000 people which actually IS just under 1/10th of the NHS staff population.

---

Dr Philippa Whitford (Central Ayrshire) (SNP) makes some good points.
She states that some 7-day GP pilot programmes have ended because of Sunday appointment uptake was as low as 12%. These come from the Challenge Fund Programme of which 25% dropped Sunday opening as there was no uptake for appointments. [14]
She brings up this [15] Bray paper regarding stroke patients and nurse coverage. This was a big paper in 2014 that found no difference between 7d consultant presence or not on weekends but a dose response relationship with number of nurses/beds with mortality.
There have been comparisons to ITU where the literature suggests no difference in weekend or weekday outcomes and this is attributed to consistent doctor levels. Actually the only consistently high staffing level on ITU is the nurses. Food for thought.

As an aside due to new government immigration laws we are likely to lose thousands of highly experienced NHS nurses next year.

---

Andrea Jenkyns (Morley and Outwood) (Con):

Opens by suggesting there are conditions that 20 years ago were a death sentence but are now easily treated. I thought this was interesting. I can’t think of a single condition that this might refer to (from 1995). Any takers?
She then suggests patients are worried they can’t see a consultant at the weekend to diagnose them. This has never even been a suggestion until now- again unsure of where this comes from but does ignore the vast swathes of registrars and junior doctors in hospital.

---

She reminds us these recommendations come from an independent body. Let’s look at that.
The DDRB is chaired by a geography professor, and the panel members do not include a single qualified health professional- they are a mix of economists, human resources and accountants-[16] and is sponsored by the Department of Health. An odd definition of independent and an odd mix of people to comment on the work-life balance and professionalism of being a doctor.

She claims that consultants can claim high fees for out of hours required patient care, again confusing emergency work (which has no opt out), elective work (of which 0.3% of consultants opt out) and locum work to cover staff shortages.

She mentions rising agency costs but nothing about staffing levels or the reason why agency staff are required, ie efficiency savings and closures.

---

Andrew Gwynne (Denton and Reddish) (Lab)

Doesn’t really add anything but reiterates a few of the above points.

---

And then…
The Parliamentary Under-Secretary for Health (Ben Gummer)
Starts out being generally and condescendingly upset about the language of the petition.
He then advises we need to be careful about the words that are said.

I thought that was an interesting bit of advice. Let’s look at some headlines after Jeremy Hunt’s King’s Fund speech;

‘Jeremy Hunt: Doctors ‘must work weekends‘ BBC News 16th July
Jeremy Hunt outlines plans for seven-day NHS, accusing doctors of being ‘roadblock to reforms’ Telegraph 16th July

You don’t let YOUR families go to hospital at weekends because it’s too dangerous: Hunt slams NHS double standards as consultants fight orders to work seven days a week
Daily Mail 16th July’

---

He begins his core speech by mentioning the body of evidence of increased mortality attributable to weekend working patterns. No one has made a attribution in hard evidence to that effect.
He then states Jeremy Hunt discussed nurses and other Agenda for Change professionals in his 7-day care remarks- which he didn’t. [17]

He mentions the Forum for Seven Day Care from 2013 as the basis for the thinking of the requirement for a seven day service. A recent FOI request however found that there was no ‘formal’ correspondence about this between Keogh and Cameron before he announced his 7 day plans. [18] which is exactly why an ideological move is now trying to scrabble for supporting evidence after it was announced. And Ben Gummer again reiterates these plans are to reduce excess mortality- of which there is no good evidence that is possible.

He then wrongly paints a deficit in the NHS of £30 billion as over whole parliament when this was an annual deficit projected for 2020 ALONE. He mentions planning to shift resources to community while forgetting to mention this government is cutting social care, public health funding and tax credits.

---

He claims one of the DDRB negotiations main issues was the opt out – despite it being used by 0.3% of consultants- and then that junior doctors will receive better pay despite the new contract amounting to an estimated 16-30% paycut.
As an aside, when confronted with these figures regarding the new contract pay cuts NHS Employers have said that the DDRB plans were only an ‘illustration’ and haven’t been finalised yet and may ‘include other income sources’. Which all sounded rather vague and creepy. [19]

He then claims that the consultant contract will require at most 1 in 4 weekend working- which most consultants already do – so presumably this is additional elective work- there was nothing in the DDRB observations about this.

He claims that basic pay rate increases should be welcomed across the board. Right now 25,369 doctors have signed up for strike [23] action due to the governments planned imposition of an effective paycut. There are just over 270,000 doctors in this country [21] and 53,000 junior doctors [22] – if all of these signatures are doctors then that’s already nearly 50% of the trainee workforce.

---

He then claims that out of hours banding pay is ‘danger money’. Let’s look at that- the under-secretary for health is suggesting all out of hours work is inherently dangerous and that we are being paid extra because of this. Inflammatory and moronic- just like his boss.

He also adds we have a right to review our own hours and apparently work life balance will be part of rostering in the new contract. I’ve read the DDRB [20] and all it refers to are ‘work reviews’ by an annual body- NHS employers or the DDRB as the ongoing committee. Given the fact that we change jobs as juniors on an annual basis this will be meaningless as we submit work reviews for jobs we no longer work in- the DDRB notes this would have to be ‘timely’- which given typical NHS HR turnaround seems unlikely.

---

He then mentions a study about acutely ill people having 3.6x more consultants in attendance on a Wednesday than on a Saturday. He is referring to the High-intensity Specialist Led Acute Care point prevalence survey [24] which asked all consultants or equivalents to report their presence / absence in 15 hospitals on two days in June 2014. This is specifically set up to compare Wednesdays and Saturdays and comes via Bruce Keogh. Yes there are 3.6x specialists in hospital on a weekday – but did we already know that? Yes. Does it make a difference to patients? Probably not. And what do you do if your consultants are moved onto the weekend and you create gaps on the weekdays?

Lastly he claims to be increasing recruitment to near record numbers for nurses and doctors and diagnostics. I can’t find any evidence of the latter and we discussed nursing recruitment at the top of this diatribe and as we know recruitment across the board of GP and A&e is already understaffed and only likely to worsen as doctors retire or emigrate in response to the above.

---

So there you have it- the debate that 220,000 people didn’t really petition for. It’s very clear we aren’t winning the argument- despite all of this being google-able in about an hour the facts thrown around by the government are not being challenged in the media and not by our own unions successfully. If you encounter these arguments you might have some more ammunition to come back with. Despite some good attempts by Helen Jones and Dr Whitford the debate ground into anecdotal and factually incorrect politik- which will benefit not a single doctor but more importantly not a single patient.

We face the most challenging time for the NHS in it’s entire history- we cannot be the generation of doctors that let the NHS be destroyed by ideologues uninterested in actual patient care. The mantra from the government is that all of this is necessary as ‘the money is running out’ due to an older population. But we have underfunded the NHS for decades, crippled it with PFI debt and then swallowed private banking debt into the national system and cut it some more. Now they want to cut our pay and remove the protections against burnout that we need to look after our patients- and this is the argument they have created to do it. They will continue to denigrate our profession and distort the evidence unless we draw a line, and manage to educate the public on what is really happening.

A simple answer for a seven day NHS would be to actually pay for it, but the government wants doctors, nurses, health professionals and ultimately patients to pay the price instead.

Maybe this time we aren’t going to stand for it.

Juniordoctorblog.com

---

*much of which was a focus on preventative and public health initiatives of which the government has cut funding. NHS England is very clear the deficit is determined by demand, funding and efficiency savings, detailing an explicit plan to reduce demand through public and social care spending- none of which has been funded. More likely the demand for services will rise even further by 2020.

**this was the first parliament proceedings I’ve read and I found it quite amusing in many ways.

***I emailed the authors regarding this point and received a short reply saying ‘this work has been done. It does not change the main message’.

[1] http://www.publications.parliament.uk/pa/cm201516/cmhansrd/cm150914/halltext/150914h0001.htm#15091415000001

[2] https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

[3] http://m.huffpost.com/uk/entry/7104674

[4] http://www.kingsfund.org.uk/time-to-think-differently/trends/professional-attitudes-and-workforce/non-medical-and-nursing-workforce

[5] 2010- http://www.hscic.gov.uk/catalogue/PUB02041/nhs-staf-over-work-cens-bull-2000-2010-rep.pdf
2014 – http://www.hscic.gov.uk/catalogue/PUB16931/nhs-staf-2004-2014-over-rep.pdf
(latest final report)

[6] http://m.warringtonguardian.co.uk/news/11601260.Fall_in_GP_numbers_not_being_addressed_says_MP/

[7] http://www.rcgp.org.uk/news/2015/february/new-league-table-reveals-gp-shortages-across-england.aspx

[8] http://www.rcgp.org.uk/campaign-home/~/media/Files/PPF/2014-RCGP-Spend-to-Save-Deloitte-report.ashx

[9] https://magic.piktochart.com/output/7136876-consultant-opt-out-figures

[10] https://juniordoctorblog.com/2015/07/18/weekend-mortality-and-the-7-day-nhs/

[11] http://www.nhsemployers.org/~/media/Employers/Documents/Pay%20and%20reward/Pay%20and%20Conditions%20Circular%20MD%2012015.pdf

[12] http://www.kingsfund.org.uk/projects/bsa-survey-2013

[13] http://www.gponline.com/exclusive-gps-rate-cqc-inadequate-requires-improvement/article/1347115

[14] http://www.pulsetoday.co.uk/your-practice/practice-topics/access/pms-seven-day-gp-access-pilot-scrapped-after-proving-unpopular-with-patients/20010222.article

[15] http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001705

[16] https://www.gov.uk/government/organisations/review-body-on-doctors-and-dentists-remuneration/about

[17] https://www.gov.uk/government/speeches/making-healthcare-more-human-centred-and-not-system-centred

[18] http://www.bmj.com/content/351/bmj.h4637

[19] http://nhsemployers.org/your-workforce/pay-and-reward/national-negotiations/q-a-on-the-new-junior-doctor-contract-proposal

[20] https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/445742/50576_DDRB_report_2015_WEB_book.pdf

[21] http://www.gmc-uk.org/doctors/register/search_stats.asp

[22] http://www.gmc-uk.org/National_Training_Survey_2015_infographic___overview_61346815.pdf

[23] https://www.change.org/p/british-medical-association-strike-action?recruiter=281072091&utm_source=share_petition&utm_medium=facebook&utm_campaign=autopublish&utm_term=mob-xs-share_petition-reason_msg

[24] http://www.hislac.org/pages/resources.html

[25] http://www.douglascarswell.com/downloads/upload13.pdf