Jeremy: let’s have a conversation

On 28th April I sat outside the Department of Health manning day 16 of the permanent protest to attempt to get the Right Honourable Jeremy Hunt to sit down and return to meaningful negotiations about this crisis we find ourselves in.
Unfortunately he declined to take up our invitation. The ‘Hunt’ chair remained empty, and we remained rather cold.Meanwhile, Jeremy took the time to write THIS piece for conservativehome.

I’m disappointed we can’t talk face to face Mr Hunt, but, in 2016, we can still have a conversation.

When I first became Health Secretary in 2012, dealing with the scandal at Mid Staffs was the first major challenge I faced.  I resolved then that my mission was to transform NHS care into the safest and highest quality possible. I knew I was not alone in this – as every doctor and nurse wants nothing less for their patients.

I think no doctor would disagree with your stated aims – but any NHS staff member would tell you that safe and quality care requires resources. Since 2010, the NHS has faced the biggest funding squeeze in it’s history, and faces unprecedented recruitment and retention crisis already, with 1/3 GP positions unfilled, and 50% of emergency doctors resigning at 3 years. Vacancies for doctors have risen 60% in the past year. Furthermore, the ‘lessons’ from Mid Staffs were laid out in the Berwick Report 2013 – here are some relevant passages;

4. Government, Health Education England and NHS England should assure that sufficient staff are available to meet the NHS’s needs now and in the future.

We do want a safer and higher quality NHS – but the prolonged age of austerity and cost cutting in the NHS has led to care going in the opposite direction, and we are deeply concerned by this.

However, one of the recurring themes has been inadequate weekend care.  I will never forget my meeting with Frank and Janet Robinson in January last year.  Their son, John, tragically died from a ruptured spleen after a mountain biking accident in 2006.  When he arrived at hospital on a Saturday lunchtime, John was left to wait several hours unattended in an A&E unit desperately short of doctors.  After a quick examination, he was sent home with a diagnosis of bruised ribs and a pack of painkillers – a decision that proved to be deadly.

This is a tragic story. But in medicine we deal with tragedy all the time – the logical response, to prevent this happening again, is to identify the actual problem, and direct your resources towards that. Unfortunately Mr Hunt you have missed the problem here.  All of your research regarding hospital ‘weekend effect’ is for patients admitted- not those attending A&E. A&E departments are equally staffed as emergency services throughout the week in most hospitals. A&E’s do however suffer from a chronic shortage of staff – an A&E in Chorley in Lancashire closed just last week because of a lack of staff, mostly because the locum doctors who staffed the department weren’t retained when the new locum cap rates were brought in. So nothing to do with the ‘weekend’ at all, but actually the chronic shortage of staff through the week.

What makes it even worse is the fact that his parents are convinced things could have been different if their son’s accident had not happened at a weekend, when hospitals usually have around three times less medical cover.

It is unfortunate this poor boy’s family believe that things could’ve been different if it hadn’t happened at the weekend. I’m sure you didn’t help their belief. The ‘three times less medical cover’ statistic you are misrepresenting comes from the HiSLaC report – which looked only at consultants attending medical inpatients. Nothing to do with A&E at all. This also included consultants with no out of hours work – like dermatology, allergy or genetic specialists, again mixing up routine and emergency care. In this sad case the specialties relevant – paediatrics and surgery, would’ve definitely been in on the weekend, as they are every weekend in most hospitals. This persistent misuse or misunderstanding of the available evidence has led some to believe that you are scaremongering. This is unsafe, and to us as a body of NHS staff, unacceptable.

This type of care is not typical of the NHS.  But nor is it an isolated anecdote: nine academic studies in the last six years have corroborated the Robinsons’ concerns about higher weekend death rates, and six of those have made a link to reduced weekend services.  

You go on to link this anecdote to ‘nine academic studies’ that ‘corroborate’ the Robinson’s experience. These studies have been well covered ‘elsewhere‘ but ALL study weekend ADMISSIONS, not A&E attendances, and none explicitly studied the actual staffing levels in those hospitals at the time. It’s more than likely this effect is due to the relatively higher threshold for admission at the weekend and presentation from patients, selecting out sicker patients who do less well overall. It’s also important to note this ‘effect’ is seen worldwide, and no health system has been able to address this, no matter the set up. It’s unlikely this is avoidable, and Sir Bruce Keogh concluded that to ‘assume so is rash and misleading’. Lastly, even if this is a true, ‘avoidable’ effect, Meacock, a health economist concluded that the cost-effectiveness of trying to address this wouldn’t reach NICE standards for a new treatment, in other words, the money would create far more benefit in other areas.

That’s why we committed to a truly seven-day NHS in the first-line on the first page of our 2015 manifesto.

I take issue with your term ‘commitment’. Most manifesto pledges are backed by funds, plans, and a model for implementation. In a recent public accountant committee Charlie Massey revealed that no one at NHS England knows how much a ‘truly’ seven-day NHS would cost, or the effect of implementation. A leaked report from the Department of Health suggested the NHS needed 4000 more doctors and £4 billion over the next five years to create- none of which have been ‘committed’. Lastly – no one seems to be clear what a ‘seven-day’ NHS is – Cameron believes it’s 7 day GPs, you have said it’s about the weekend effect, Keogh talks about urgent and emergency care. A 10-point study looking at ‘Seven-Day’ services found medical cover to be at 100%, but social care and mental health lacking- these areas definitely have not been ‘committed to’.

Junior doctors are in no way to blame for this ‘weekend effect’: they already do the lion’s share of weekend work. But the contracts for both juniors and consultants were drawn up over a decade ago with Monday to Friday services in mind.  To deliver our manifesto pledge, we need to reform both of these contracts to make it easier for hospitals to roster more doctors at weekends, alongside improving a whole host of other weekend services including diagnostic tests, pharmacy, physiotherapy, GP access and social care.

This is difficult to address. In the same paragraph you state that junior doctors are in no way linked to the ‘weekend effect’ you then claim that contract reform is required to roster more doctors at the weekends. If they are not linked, then why is this a priority? The assertion this is Monday to Friday services is false- these contracts were drawn up to prevent overworking doctors and preventing exhaustion related-mistakes. And, to my knowledge, none of your other ‘weekend services’ are in place or in the pipeline.

The reaction from the doctors’ union, the BMA, has been disappointing in the extreme, culminating in the first ever withdrawal of emergency care this week. We worked hard, and in good faith, to reach a negotiated agreement: we held 75 meetings; set up three separate independent processes to move the process on; and made 73 concessions in the last year alone.  On the final sticking point of Saturday pay, we made three successive changes – ending with an offer that sees anyone working regular Saturdays get more generous overtime rates than nearly any other worker in 24/7 industries, from nurses, paramedics and midwives, to police officers, fire-fighters or airline pilots.

The logic starts to fall apart here. You’ve already stated that junior doctors aren’t linked to the ‘weekend effect’- so why have you pushed so hard for a new contract, so hard that it’s alienated an entire section of the workforce and created multiple damaging strikes. Simply stating the number of meetings is as pointless as stating the number of concessions – that could reflect how ‘hard the government has worked’ or it could reflect how difficult and intransigent it’s been, shooting down every BMA suggestion, proposing a complete disaster of a contract and then claiming that each ‘concession’ is an ‘act of good faith’. Let’s put it this way – if I proposed to burn your house down, and then we negotiated, and I concluded that actually I won’t, that is hardly a concession. That’s common sense prevailing. You say that the ‘final sticking point is Saturday pay’ but here is a letter you wrote to Mark Porter saying the remaining issues include;

-Non-resident on call arrangements
-staffing and seven-day fund implementations
-workforce requirements

Not to mention the Equality Impact Assessment that your department produced that specifically ‘discriminates against women’ as a ‘proportionate aim’. As for ‘more generous’ Agenda for Change staff banded 4-9 get 30% on saturdays, and 60% on Sundays, band 1 gets 50%. Comparison to airline pilots is ridiculous – their ‘rest’ requirement arrangements and strict safety rostering far outstrips anything you have proposed.

Unfortunately, this wasn’t enough for the BMA, who tore up a written agreement to negotiate on Saturday pay and refused to budge at all from their opening ask of time and a half for all of Saturday and Sunday. In the end, a respected hospital CEO I had asked to lead the discussions advised me that a negotiated solution just wouldn’t be possible, so I reluctantly decided to press ahead with the new contracts without agreement.

I’m just going to ignore this. From a legal point of view however, I would like to ask if by ‘press ahead’ you mean ‘impose’. The courts in a few weeks time will be very interested in this, as it may seem that you do not have the power to impose a contract in this manner at all.

The last thing we want is a ‘miners moment’ in our NHS, but the BMA have made their unreasonable demands and extreme strike action a test of whether a powerful union can veto promises made by an elected Government.  

This is what it comes down to here, and that is the tragedy. The BMA have made ‘unreasonable demands’ – and your interpretation is this is a ‘union’ vs Government political moment. This isn’t – this is a group of doctors worried about their patients and the survival of their profession within the NHS – if you see it like that,  and step back from this political brinkmanship, maybe you will be willing to begin talking to us again.

I know that increasing weekend medical cover as part of a wider programme to improve services seven days a week is the right thing to do for patients, so I am not going to abandon reform simply because it has become difficult or unpopular.

Again – if you want to ‘increase’ weekend medical cover, but you don’t think this is related to ‘junior doctors’ – then what exactly is the point of this whole protracted conflict? If you think a wider programme could ‘improve services’ then the logical thing would be to trial it. This option was offered on Monday pre-strikes. But you refused.

Labour Ministers made that mistake, giving in to BMA demands on the 2003 consultant contract and 2004 GP contract.  The result was a ballooning pay bill and a dramatic reduction in weekend and evening cover. We must not make the same mistake.

Again, you are mixing consultant and GP contract negotiations with junior doctors, as you well know they completely separate.

The NHS faces profound challenges: so, this year, we are putting in the sixth biggest funding increase in its history to support it. But with money must come reforms that benefit patients – so that we can deliver our Conservative dream to make NHS care the safest and highest quality in the world.

Please stop telling everyone you are putting the ‘sixth biggest funding increase’ in NHS history – relatively this is true. But if I didn’t pay you for a week, then claimed the next week to give 10% more wages, you wouldn’t be happy if I said this is a ‘huge increase’ on your normal wages, you would still want your pay last week. The same can be said of the NHS – this decade was the least relatively funded in it’s history, at an average rise of 0.9%/year. This is including the ‘extra’ £10 billion proposed by this government by 2020. The average rise per year, to account for health inflation, is 3-4%. The government has not been meeting this cost. No one honestly believes you can make the NHS the safest and highest quality in the world, without equivalent investment to the rest of the world.

I’m glad we could have this talk. If you want to sit down again sometime, one of us will be outside your door, any time, any day of the week. There’s a chair with your name on it.

juniordoctorblog.com

“There’s not a lot of sense from government right now.”

Ben White, junior doctor, campaigner of NHS no. 1At Xmas and Justice for Health, quit his training job on national television this morning.

In his response something he said resonated with me- “there is not a lot of sense from government right now.” To my mind this phrase  encapsulated the whole dispute.
Ahead of the first full NHS junior doctor walk-out in history now seems a good time to document the completely insane handling of the process.
The ‘Weekend Effect’

Supposedly this all started with Hunt and colleagues ‘discovering’ that patients admitted at weekends had a slightly higher chance of death than weekdays. This whole concept has taken a rightful battering;

What we know about this now is:

– The study was commissioned by government

– The independence of key authors is questioned

– The study showed no link to junior doctor cover

– Pending studies of the same data may show no ‘weekend effect’ at all

– It’s likely sicker patients are not properly adjusted for

– It’s a phenomenon seen worldwide, which no health system has been able to understand or ‘fix’

– The study concludes its unlikely this ‘effect’ is actually avoidable
So, not a great start. From this starting point, we are told, the government began the drive for a ‘Seven Day NHS’
The Seven Day NHS 

A ‘back of the envelope’ idea from the last conservative manifesto.
– originally led by Sir Bruce Keogh

– The actual plan was originally to improve urgent and emergency care, then create elective work throughout the week

– All heads of the NHS said this would require additional funds, staff and years of planning, outside of additionally needed funds to keep NHS going at current service

– A ten-point survey of ‘Seven Day’ criteria found medical cover at 100%, while most other services were between 50-60%. The cut off for finding a service “7-day NHS” ready was 70%. So nearly there without any massive reorganisation required.

– The 7-day NHS criteria desperately fell down on social care and mental health- both areas savagely cut by this government

– Hospitals touted as already ‘7-day’ like Salford Royal, have neither routine elective weekend work or a new contract. They did however spend additional funds and recruit extra staff.

– After a year of ‘7-day’ NHS policy speeches, NHS strategy head Charlie Massey revealed they didn’t know how much it would cost, how many staff would be needed, or what it was. He was told he was ‘flying blind’ on the issue

– A leaked report from the DoH showed that it would need 4000 extra doctors, funding of£0.9 billion/yr or £3.6 billion by 2020, and likely would not change the ‘weekend effect’.
So, you are a government in power- you misidentify a problem, create a nonsensical plan to try to fix said likely unavoidable problem, don’t fund it, plan for it or cost it, and then try to improve upon the existing 7-day cover for doctors, already at 100%, while ignoring the huge 7-day service gaps in social care and mental health that are a genuine problem.
Make any sense so far? No? It gets worse.
The Junior Doctor Contract

Into this mess was ‘imposed’ this new contract.

What we now know about this:

– it will cut pay for junior doctors coming into the system from August, and all doctors by 2019.

– It removes all previous safeguards on overworking doctors, and removes ‘real-terms’ fines for hospitals who make illegal rotas, replacing the system with part-time guardians schedules to work just 4 hours/week.

– Cass Business school said the proposed rotas under the contract risked jet lag, and may ‘breach employer duty of care’

– Remember no study showed junior doctor cover at any time was lacking already

– The contract discriminates against women and parents, by the governments own admission

– The legal power to impose is being challenged in court

– Negotiations have been ongoing for three years- there is no pressing need for new contracts

– This contract is completely untested and unmodelled- trusts need more doctors to implement it safely as it is

– A ‘junior doctor’ is any qualified doctor up to consultant level, 10-12 years of working. There are ‘junior doctors’ who have been doctors longer than Jeremy Hunt has been an MP.

– The contract began as a cost cutting exercise amongst a group of NHS execs in the south west
This has to have been one of the most damaging instruments of government policy in NHS memory. So if this contract won’t fix the problem that may not be a problem and actually ignores the real issues in the NHS, then one has to ask, why bother? Does it make sense to any of you?

The NHS

The NHS is in real peril. Here is a rundown.

– The government ‘promises’ ten billion pounds over 5 years. This would push NHS funding LOWER in the OECD %GDP tables than it is now- to 6.7% which is lower than nearly all of Europe. France and Germany spend 11.1%, the US nearly 18%.

– Prof Don Berwick, former NHS safety tsar, said ‘I know of no country attempting to fund modern healthcare on 8% GDP, let alone 6.7%.’

– This is because NHS costs rises every year – this is called health inflation.

– If you cut funding, you don’t treat patients promptly and properly, they get sicker, and it costs more

– This creates a vicious cycle- where we are now

– Waiting times in A&E are at an all time high

– Hospital Trusts this year will reach a record £2.8 billion in the red- this is because hospitals refused to cut staff to save money, and overspent the budget from The government to keep patients looked after.

– GPs received 12% funding of NHS budget in 2010- this fell to 8% this year. With the government new plan of £2.4 billion this will still be only 10% by 2020.

– Recruitment and retention for medical and nursing staff is in trouble with rising vacancies

– An A&E in Lancashire closed last week because of a lack of doctors

– Meanwhile private companies are buying up services. 500% increase last year alone.
So is the solution to this mess increasingly aggressive political posturing, imposing a contract that is destroying morale, in a bid to fix a problem that doesn’t exist through a programme that doesn’t have a budget or a plan?! Rearranging the deck chairs on the Titanic isn’t even half of it. This is insane.
So when Ben White says “the government isn’t making a lot of sense” that’s TV politeness for – this government has lost all sense of governing. Whether that’s incompetence or incomprehension of the massive danger the service and the patients are now in, it’s hard to tell.
You might think that the strike tomorrow is extreme, but when faced with such an extreme scenario, what else can we do? A sensible offer of proper research and a trial of the new contract was put on the table yesterday by a cross-party group of MPs. The first sensible thing government has done for the NHS in years.

And of course rejected out of hand by Messrs Hunt and Cameron.
This is madness, not from junior doctors, but from a government set to destroy the NHS.
I think it’s time to send in the people in white coats. We are outside your doors Messrs Hunt and Cameron, a quiet word please?
Juniordoctorblog.com

Do no harm does not mean do nothing

It is a common misconception that the only principle of being a doctor is ‘Do No Harm’.
The four pillars of medical ethics, beat into us at every exam and interview, are thus;

“Beneficence, justice, autonomy and non-maleficence.”

Let me explain. Beneficence simply means ‘do the best for your patient’, or more simply ‘always act in the interests of your patient’.

Autonomy means ‘respect the individuals right to make their own decisions’, and this often comes into conflict with the first pillar. The best medicine for my patient might not be one they want, or their decisions might bring them to ill health e.g smoking, but that’s their right. Some patients may not have full autonomy- advanced dementia, confusion, even being drunk. Then we act in the best interests of the patient, and do what we can.

Justice means different things to different people, but essentially is ‘treat all patients fairly and equal’, but each decision must be right for the individual patient, and respect their wishes.

Finally, non-maleficence is the infamous ‘do no harm’, but already you see the complexity. ‘Do no harm’ does not mean do nothing.

Take for example an operation to replace a broken hip. Have you ever seen it? A vital, life-saving intervention for an older person who breaks their femur (the long leg bone that ends at the hip)- it starts with a long slash across the thigh, followed by wrenching and cutting through the thick muscles to the bone itself. The head is sawn away and ripped out, the cavity ground down and shaped with power tools, a metal head chiselled and rammed in, then hammered into the existing bone. Blood flies out, cement pours in. It’s one of the most brutal things I’ve ever seen done to a human being. It certainly would constitute ‘harm’, but it serves a higher purpose- the beneficence of the patient, ie a new hip, restored mobility, and a better chance of longer life. The same could be said of nearly everything medicine does- from the needle puncture for a blood test to the toxic side effects, and indeed intended effects, of chemotherapy for cancer. To simply say ‘do no harm’ means ‘take no action’ neglects the fundamental balance of risk and benefit that underlies all medicine.

Every decision therefore is usually a conflicting mix of all of the four pillars of medical ethics, and we must synthesise every part of the law and of our own conscience to act in the best interests of the patient, fairly, safely and in line with their own wishes.

Now apply this view to the next junior doctors full strike, with emergency care juniors walking out as well.

We’ve heard plenty about the ‘do no harm’ argument – the government has lined up everyone on the payroll to give their two cents in the press. Darzi, Stephenson, Keogh, Davies. Some retired guy that resigned as chief medical officer 15 years ago.

But does it actually add up?

Let’s look at the situation on the ground. There are around 44,000 consultants in NHS hospitals, 54,000 juniors Doctors and 10,000 non training and dental staff. On any given emergency day, such as the Royal Wedding, the number of junior doctors that cover emergencies only is around 10-30% of the workforce. So in a full walk out, assuming everyone does walk out, you would need about 5000-18,000 doctors to replace them to provide emergency care. You have 54,000 non-junior doctors, consultants and other non-training doctors, on payroll, who also happen to be the most experienced doctors in the hospital. That’s without preparation. Hospitals are taking proper measures to ensure safety, led by our consultants and managerial colleagues. In fact, with the active movement of additional blood taking and clinical support staff to wards, the deployment of several consultants per striking junior, and proper bed management, some hospitals might even be the safest they have ever been. So the proposition of significant ‘harm’ is logically unlikely.
What about autonomy? The government spin machine would like you to believe we have none, we are ‘misled’ by our union, and we do not have the ability to make decisions ourselves. This movement has been led by the grassroots from the beginning- the hashtag #iminworkjeremy trended nationally in July 2015, from everyday doctors in response to the first shots from government over this contract in the press, not the BMA. Since then it has been the grassroots at the forefront, driving the BMA. Not the other way around. It is our jobs to take large volumes of information, synthesise that and make a complex decision, and then take responsibility for that judgement. To say we act without understanding is ludicrous.

What about beneficence? Much of the public don’t understand this issue, and for that we apologise. It’s about making a workforce cheaper, removing safeguards that cost hospitals money, and stretching lucrative elective weekday work into the weekend. It is, as it always has been, about money for the government, at the cost of safety. We recognise that, and we recognise that this contract will create dangerous conditions for patients, crippling retention and recruitment at a time when the NHS is already on the brink. An A&E in Lancashire closed last week due to lack of staff- we have a long term duty to patients to make sure that doctors have safe working hours and staffing levels.

Lastly- justice. I take this pillar of medical ethics to mean that every member of society should have the same healthcare, should be treated fairly based on need alone. The NHS is one of the most just and equitable healthcare systems in the world, and it is being summarily destroyed. We cannot stand by and watch this happen.

We are trying all we can to avert the next strike- we don’t want it, but it is the only treatment option we have left.

We want to talk- for the past six days doctors have been camped outside the DoH waiting for Jeremy Hunt to open his door and begin negotiations again.

In the fight for justice and beneficence Justice For Health are taking Mr Hunt to court today, issuing proceedings officially at 4pm. Their aim is to have the High Court review the government’s actions on the contract and the NHS and decide if this is safe and rational. A win in the court could avert this whole mess, a step in a new direction to save the NHS.

But they can’t do it without your help- Jeremy Hunt is trying to bully these crowd funded doctors with threats of huge costs, demanding £33,000 up front to even get the case to a judge. He is trying to use the deep pockets of the government to put down a safe, effective and reasonable intervention against a dangerous contract.
Will you help us?

http://www.crowdjustice.co.uk/case/NHS
Do no harm does not mean do nothing. If you want justice, for the long term benefit of all of us, do this.
Juniordoctorblog.com

This is what a dying NHS looks like.

In the grand scheme of things I haven’t been a doctor long. There are consultants who qualified as doctors before my parents even met. I have however seen my fair share of patients, and working with some of the sickest groups in the hospital, I’ve seen plenty of deaths as well.

Most very unwell and terminal patients will die in similar ways. As with any large and very complex machine, there are usually predictable stages. The first signs are the subtlest and most varied-the kidneys might slow down, the peripheral vessels might close down, the brain might become forgetful or sleepy. Then slowly more parts of the whole stop working- each has a knock on effect to the next, with predictable decline. It’s possible to intervene of course- modern medicine can breathe for you, be your kidneys, even pump your heart if needs be. But sometimes we cannot fix what is wrong, and it’s not always right to do so.

Once one major organ fails, another shortly will, and then the next. Beyond this point the damage is usually irreparable. Things deteriorate slowly, until suddenly, whatever spark of life that keeps you laughing, crying, loving and moving, the spark that makes you YOU, is gone.

Why all the morbid tales you may ask?

Because for months and years the NHS has been in slow decline.

Because the end of the NHS isn’t in five or ten years time, it’s staring you in the face, right now. Today.

To the experienced eye, the signs have always been there.

First- the disease. Diagnosis is always difficult. The same pressures of increasing complexity, increasing possibility and increasing age of the population haven’t really changed. Healthcare inflation is well recognised. But the increased work load has been met by starvation, and waste. Austerity, massive reorganisation and criminally expensive private finance deals have smothered the system. Deprived of funds, the NHS began to wobble.

Subtly at first, waiting times crept up and A&E and maternities began to close. NHS finances dipped, a pay freeze hit staff, a mild winter spared us, and the NHS limped on.

But now the organs are failing. Waiting times in A&E have reached a record high, and today this happened. Lancashire Teaching Hospitals Trust A&E, due to being unable to recruit sufficient staff in a combination of lack of retention and capped locum rates, is left with either closing their A&E or calling in the army.

Let me just reiterate that- an NHS A&E is considering calling in the army to prop up services. Calling in the army. This is what a state of emergency looks like.

This is what a dying NHS looks like.

The other organs are rapidly declining as well. Due to threatened nursing bursary cuts and immigration law, the life blood of the NHS, our nurses, are failing. We are bleeding out losing experienced staff and failing to recruit sufficient numbers to replace them.

The ‘backbone’ of the NHS, the junior doctors, is being crushed – by rota gaps, by overwhelming pressures and by rock bottom morale. Is this the time to introduce a toxic, unmodelled and unsafe contract? We are trying to hold up the service like everyone else, but we can’t do it anymore.

The NHS needs urgent intervention, we need funding and we need politicians who value the service, not butchers to carve up the carcass to private companies. 

If you don’t believe the Tories would destroy the NHS it’s time to face reality. It’s happening right now. The NHS is critically unwell, and whether it’s deliberate or not, death’s door is open.
Don’t stand by and watch it die.

 

How to solve the health crisis. Leave us alone.

Dear Messrs Cameron, Osbourne and Hunt,

You may have noticed the NHS is doing pretty badly lately; funding is at a record low, waiting times are at a record high, and morale across the service is at rock bottom.

You all made some silly promises about money- that’s okay, we all say things we don’t mean sometimes. You perhaps got a little confused and said that you were committing “half a trillion” pounds to the NHS over this parliament- which is simply the current flat yearly budget (~£100 billion) x 5 years. You said this was ‘the most amount of money ever given to the NHS’, but you might remember every successive government since 1948 could have said the same- it’s called health inflation.

You may have forgotten about that when you said you were ‘committing 10 billion‘ pounds ‘extra’ to the NHS, to fund the NHS ‘own’ plan. Except it wasn’t the NHS own plan– it was yours, and it’s not nearly enough even to keep the lights on.

Everyone’s a critic eh? It’s not nice when people say you’ve done a bad job, so I can fully appreciate why you asked hospital accountants to hide the debts under their carpets, and told hospital managers to pay for less nurses and doctors last year. I can feel your annoyance when hospitals decided that wasn’t safe, and had to hire lots more agency staff to fill the gaps. You said some silly things blaming this on agency fees, but that’s okay, 80% of the cost of this was the gaps themselves, and you won’t make that mistake again next time will you? Will you?!

You’ve said some funny things about the health service. You’ve said you want it to be the ‘safest health care system in the world‘, but I think you also want it to be the cheapest in the industrialized world? I picked up a few bits for you to read- might help. This one shows increased funding improved outcomes in healthcare. This one shows big reorganizations in healthcare don’t work at all.

You’ve said some things which, I think, aren’t true. I do hope I’m wrong. You said you were committed to keeping the NHS public – but Virgin just bought huge swathes of services, and private company contracts increased 500% this year. You have neglected to mention this, but that’s okay – government is busy work, and not everything can be in every speech. Some people might not mind NHS privatisation, but I do think you should let them know.

You’ve handled the junior doctor contract rather badly. I don’t think it’s unfair to say so. 98% of ballotted doctors voting for strike action, the first doctors strike since 1970, the first ever emergency walk out in NHS history, record levels of dispersal, record low morale. Can I make some suggestions? Have you thought about just leaving them alone?

Since 2006 they have had a £6000 one off pay cut, then a further cumulative 25% pay loss while working in the busiest and least funded decade in NHS history. But no one really complained, bar a half-hearted effort in 2012. I don’t think this is about money, but understand the context.

Doctors conditions are already poor and retention is already a problem. Record levels of doctors leave training after two years, vacancies and rota gaps have increased 60% in two years, and 1/3 GP training posts and  50% of year 3/4 A&E registrars resigning.

So what’s the hurry? Do correct me if I’m wrong, but if contract changes are cost neutral, but could threaten recruitment and retention of staff at a time when the NHS is under incredible pressure, and doctors say is categorically less safe then current conditions, one has to ask, why bother? Why not talk for another year, rather than strikes and strikes, and resignations. Not to mention the reversal of all equality workplace gains in the last decade. Mr Hunt wanted ‘certainty’ in the health service- but I cannot imagine a more uncertain time.

Why not just leave us alone? It’s not too wild an idea. You might say the BMA asked for contract negotiations and therefore the contract must change. This is like inviting your friend for tea, punching them in the face repeatedly and then wondering why they wanted to leave. You can’t force them to keep having tea at your house, and if tea isn’t essential, then why would you?

It might hurt your feelings a little bit, but that’s okay. We all have little tiffs, we all make mistakes. No need to be too proud about it. After all, why would you want to wreck a whole health service just to save face?

It must be a tricky job, being in charge of everything. Why don’t we just sit and talk for a bit, about how we might all make the NHS better?

Unless of course that’s not what you want at all. Unless you have decided that with four years of government, a weak opposition, and deep pockets controlling >50% media and the BBC, you might decide to ram through as much toxic and undemocratic policy as you possibly can. Kamikaze politics, with a hope some strong PR spin at the end will still save the next election? So why not ram through massive NHS-reorganisation and sell off, privatise the schools and the land registry, cut disability benefits and cut corporate tax, cut funding to the opposing party and turn the BBC into state-run television. Why not in fact trample the entire fabric of democracy, safe in the knowledge that the public are too apathetic to offer any significant opposition?

You are leaving them few choices Messrs Cameron, Osbourne and Hunt. Strike or resign. Perhaps it’s #timetolisten? Or better yet, just leave them alone.
Juniordoctorblog.com

Dear Other Normal Human Beings

As relevant today as it was 9 months ago…

Dear Other Normal Human Beings,

I am writing to you, because, like myself, you are a normal human being.

You, like me, wake up in the morning and sleep at night, eat meals, sometimes with loved ones, sometimes alone. We are alike in our requirement for other people, for happiness, for security, for food, for warmth, for shelter.
You may have children, you may have brothers or sisters. You have, or had, parents, and perhaps were lucky enough to know your grandparents.
You may have noticed that many health professionals are becoming uncharacteristically vocal. You may have thought them self-serving, morally bankrupt individuals, upset over their own pay packets.
I would like to explain to you, from one normal human being to another, what is going on.
I am a doctor. I decided to be a doctor before I really knew what decisions were, and can never remember wanting to do anything else. Once I knew how, I found the path, and worked my arse off. Six years, in secondary school, studying. Two years, in college, studying. I took four A-levels, I had 25% less free time than my friends, and when they were out, doing whatever they wanted, I was not. I was studying. Another six years at medical school, studying, and sometimes working to pay for the studying. The last three years of medical school I worked harder than I ever had, and the same hours as a full-time professional, sometimes way more. It even made me sick- in my final year I developed acute gastrointestinal bleeding. But, becoming a doctor was all that meant anything to me. So, I took my top grades and turned them in, in return I got fourteen years hard graft, and £50,000 worth of debt. [2]
Why is this important? Because, from the very beginning, I knew about sacrifices. As thousands of my colleagues have, as millions before me have, and millions will. I knew about sacrifice when I worked for a year before university, so I could afford the rent, when I missed my first family Christmas to work as a warden in student halls, so I could afford to stay at medical school. I knew about sacrifice when I missed nearly every other Christmas since, working, or sometimes studying. I knew about sacrifice when I’ve missed my friends weddings, my nieces and nephews birthdays, when everyone I knew was travelling, and I was studying, or working. Being a doctor, and it’s inherent position in society and in the hearts of the public, is irrevocably tied to sacrifice- it’s the dedication it takes to become, and to stay, a doctor, that by definition requires sacrifices to time, to personal satisfaction. All over the country right now, doctors and nurses, physiotherapists and occupational therapists, radiographers and ward clerks and all the other medical professionals are sacrificing their lives, minute by minute, to try to give you or your loved ones minutes, hours, days or years more. So, when, as a normal person, someone tells you doctors don’t understand ‘vocation’, you know now- it is beat into us before we even get through the door.
But, as a normal person, of course you understand why doctors would defend the NHS, would fight to protect it, and so vociferously attack it’s detractors. They have a vested interest, they want to keep their cushy salaries and great jobs, and the NHS is great for that.
Let me tell you straight: if I didn’t care about you, or my patients, I would be out there campaigning to close the NHS right now. I would make more money in the private sector in a day than I would in two weeks of NHS work. I could also take my UK Medical degree, one of the most respected qualifications anywhere in the world, and go and earn 50-200% more in the US, Australia, New Zealand [3]. In the private sector, if I stayed after 5pm to look after you, the next thing you see after my smiling face as you exit the hospital, will be the bill on the doormat; ‘overtime’, ‘time in lieu’, ‘additional hours rates’ aplenty.
But, I, like you, have a family. I went to state school, and worked and grafted to pay for my six years at University. Without the NHS my grandmother would have gone blind, my father would have had several heart attacks, my mother would have died. I might have died. A private system would’ve bankrupted them, ended their hopes for a better future in order to pay to survive. I, like you, would do anything for the ones I love, and that is why I campaign to protect and improve the NHS. And that is why, when 5pm comes and goes, as does 6pm, 7pm and all the other hours in between, I, and every colleague I have ever worked with, stays for their sick patient. Because, one day, somewhere, for someone else, that patient will be their mum, or dad, wife or husband, son or daughter.
We have had, and always have had, the extraordinary privilege of one of the greatest healthcare systems, pound-for-pound, in the world. The reasons for it’s great outcomes and low cost are debatable. But there are some reasons we never mention. This country has a medical school system of international renown, whose doctors, for the most part, qualify and stay exclusively working within the NHS. The staff of the NHS gives untold free hours to the profession; when I was a first-year junior doctor, I calculated I worked one day at work for £4.10 an hour. I used to get paid more at Tescos. But a very sick patient needed a lot of complex care, and so I stayed, and helped, and he survived: as millions of patients have since 1948. [4]
The moves of the current government against the medical profession are calculated: to deride working conditions, salaries, hours and deplete hospital resources, until a normal person, like myself, buckles under the social, financial and emotional cost. At that point, a sea-change of new, private hospitals will open, and we will go and work there. And our lives will be pretty much the same- different bosses, the same bureaucracy and probably better pay. But our lives, as normal people, will not. You will still pay taxes, a stripped-down NHS will persist, for no frills, emergency care only, but not for all the other healthcare needs of a 21st century population: you will need private healthcare. And that healthcare insurance will cost you hundreds of pounds a year, if not a month. And if you don’t have insurance, you will spend thousands of pounds on the simplest, quickest procedure [5]. And the NHS won’t be there for my family, or the families of normal people across the country.

So, I want this to reach as many normal people as it can. If you don’t act now, it will be too late. It might already be too late.
We care deeply because we can see the great good the NHS does, every single day. And I care because, like you, I care about the ones I love.
Where can you start?
Here might be a good place:

Www.crowdjustice.co.uk/case/NHS

We are taking the government to court, to show us they aren’t gambling the future of the health service away on an unmodelled and unsafe contract.

If you want an NHS at all it’s time to help.

Yours sincerely,
juniordoctorblog.com
[PART 2: A Factual Appendix]
-What normal people appreciate, are hard, solid, unflinching, facts. So here they are.

[2] Medical students studying now can now expect to pay £9000 pay a year as of 2015 for six years for most courses: that is £54,000. Most will require a student loan to pay living expenses for a full time course, at a further £5000 a year that totals £79,000 for six years study. Maintenance grants for the poorest students have been scrapped, adding an additional £10,000 debt as a minimum.

[3] Starting pay for any consultant in the UK : £75, 249. In the US: £111,799.80 for internal medicine, £183,152.91 for a radiologist. ($/GBP rate correct at time of writing). In Australia: a basic salary of £78,000 for internal medicine consultants, BUT this is for a 38 hour working week. Average overtime and up-scale pay between £92,526.97- £244,366.10. Same with New Zealand for a 40-hour week, after average overtime and up-scale up to £128,039.69.
UK data: http://bma.org.uk/practical-support-at-work/pay-fees-allowances/pay-scales/consultants-england

US data: http://www.payscale.com/research/US/People_with_Jobs_as_Physicians_%2F_Doctors/Salary.

Australian data: http://www.imrmedical.com/australia-salaries-tax

New Zealand data: http://www.imrmedical.com/new-zealand-salaries-tax
[4] The NHS opened it’s doors, metaphorically, July 5th 1948. It’s first patient was a 12-year old girl with a liver condition. http://www.legislation.gov.uk/ukpga/Geo6/11-12/29
[5] This is incredibly interesting reading, although it is for claims, it is still very reflective of the actual cost. https://www.freedomhealthinsurance.co.uk/downloads/your-choice-procedure-payment-guide

Diary of a Junior Doctor 2017

August 1st
Whew. Just got my new contract! Very exciting. I’ve heard good things from government; safer, better paid, more training opportunities. Just coming in to registrar training after a year in research so excited to be back in the hospital. Obviously all this ‘ pay protection ‘ doesn’t apply to me, but never mind! They’ve given me a ‘training agreement’ to sign, allows them to roster teaching on evenings & weekends apparently, sounds great! Signed and sent.
First day tomorrow.

August 2nd
Started today- got given my ‘work schedule‘. I thought I was supposed to go through it with my educational supervisor but they haven’t assigned me one yet. Doesn’t look like rotas I remember. Here is my first week:

Wednesday– Long day 8-21.00
Thursday– Normal day 9-17.00, On-call from home to 0800am
Friday– Night 10pm-0800am
Saturday– OFF
Sunday – Night 8pm – 0800am
Monday– OFF
Tuesday– Long day 8.00- 21.00
Wednesday– Long day 8.00-21.00

Anyway, let’s see how it goes! Had my wife Jane look at it, she’s on maternity leave from surgical training at the moment with our 11 month old, and she wondered how it would work.

August 3rd

Whew! Tough first day. The hospital hasn’t filled the other registrar post yet, so I’m on my work schedule alone. Had both bleeps today, very busy, back and forth to A&E, plus did both ward rounds. Missed teaching and had to leave the training list early to see sick patients on the ward. Handover was a bit odd- one registrar was starting for the night at 8pm, and the other was working 2pm till 10pm. Not sure who was responsible for what. Quite confusing, team members turning up at different times, ended up staying till midnight trying to make sure everyone knew about the patients and plans were in place. Got home at 0100am. Jane not pleased. Rocky start.

August 4th

Had a read of the contract today- apparently I need to be reporting long shifts like last night, and should get paid for work done. Phoned an HR lady, a Ms Massey, who said as work wasn’t ‘approved’ they don’t count it. I asked her who it should be ‘approved’ by and she didn’t know. She told me to send an ‘exception report‘ to my supervisor. Tried again with my educational supervisor- apparently she’s on annual leave for the next week so will speak to her on her return. Anyway, will get some pre-bedtime time with Jack tonight, finishing at 5.00. Will have the on call phone but the trust estimate that should get five hours sleep and work maximum 25% time apparently. Sounds reasonable.

August 5th

Oh my god. Last night was horrendous- called back in to work just as I walked in the door, didn’t manage to stop working till handover, a 24 hour shift! This can’t be safe. I hope all the on calls aren’t this bad. Exhausted. Note to self: try and find this Guardian of safe working I’ve heard about. Got home just in time to take Jack to play group for an hour. He was chuffed to see his dad and mum in the same place for once. Had to go straight to bed when we got home- back to night shift tonight.


August 6th

Eurgh. Saturday. I think. Woke up at 2pm after another busy night shift. No one to hand over to in the morning- had to stay till 10.00 till the next shift person arrived. Apparently a gap in someone’s ‘work schedule’. So I’ve worked 10 hours on a day it says ‘OFF’ on my rota. This is chaos. On another night shift tomorrow. Must get some sort of work review– already! Don’t want to rock the departmental boat but this can’t be safe for anyone.

August 8th

Monday morning. Tried to stay in the hospital after another night shift and find out about supervisors and guardians. No joy with the supervisor- the covering consultant has too much to do with their own trainees they can’t do a review with me. Found out the name of the Guardian- a Mr Angel. Called his office- secretary said he had no appointments till October now, and work reviews are a six week process, and I need to submit in writing. I asked why and the secretary was a bit snappy with me- “Mr Angel is working very hard but covers three hospitals so what do you expect?”. I asked around- the BMA can’t do hours monitoring anymore. Maybe I’ll try them anyway. Don’t know what else to do. Long day tomorrow.

Aug 31st

Wow. Got my payslip today- can’t really work it out but I’m earning less than my 1A banded job two years ago. There’s more coming out for pensions now, I don’t qualify for Saturday uplift because Friday night shifts start on Friday, and the on-call work pay is estimated in advance, so it’s about £2.80 an hour. Driving back and forth at night is becoming dangerous, so I asked for accommodation to be on site overnight- apparently this has to be deducted from my pay, so I now owe the hospital money for every on call shift I work. What the f**k.

My wife’s off mat pay now so we are a bit stuck for the mortgage. I’ll probably have to do extra locum work, but I don’t know where it will fit in these rotas.

Sept 5th

Exhausted- we’ve had two resignations in my department, one first year and the other training registrar. No ones replaced them yet. Got called in to cover a shift this Saturday – Ms Massey told me it was expected for us to cover, and didn’t qualify as a locum. She gave me a day in lieu, but can’t tell me when I can take it. Missed Jacks birthday. Pretty gutted. Sent ten ‘exception reports’ in the last few weeks and no response. Where do they all go?

Sept 6th

Got hold of my educational supervisor- she seems nice enough, agreed the rota is looking dangerous but has already sent exception reports and work reviews off and awaiting replies. She doesn’t know who to escalate to either. She tried to make ‘pay amendments’ already but HR won’t accept them. The medical director is trying the Guardian but Mr Angel has just gone off sick with stress, and there’s no replacement as yet. Off the record everyone’s quite unhappy. Jane is looking at going back to work but it isn’t looking like with childcare we will be able to manage both of us, and it seems if we went part time we’d only get ‘allocated leave‘ so no chance of ever arranging time together and if we went part time we’d get paid less per hour than full time. That can’t be right? For the same work?

Sept 14th

This is getting dangerous, I’ve tried to raise it with my on call consultant– a locum this week, no clue what I’m talking about. No one is in charge of our hours and every week the rota is filled with gaps and odd hours. Our patients don’t know who is looking after them at any given time, we spend whole nights working flat out without rest, with no one to report to. People are dropping like flies now- I have had two locums on every shift for the last week.

In the meantime my work review is now ‘closed‘, as ‘rostered’ hours are within contract. I can appeal if I want. I tried to get some leave but my ‘allocated’ leave was overruled due to lack of staff, and I can only take leave on ‘normal’ days which is usually once a week. We cancelled our holiday plans. I missed Jack’s birthday and haven’t been at home with the family, awake, for a whole weekend for six weeks. It’s getting tough with Jane.

Oct 1st

I managed to get through to the new Guardian- this one is one of the board of directors at my hospital. He’s rejected my appeal for a work review, citing ‘exceptional pressure’ on the hospital. He gave me an appointment to resubmit in 6 weeks- I pointed out I will have moved to my next job by then. He didn’t care. I snapped. I can’t do this anymore.

Oct 10th

I spoke to the BMA today- they don’t have any powers beyond issuing reprimanding letters, which they already have. I’m burnt out, I feel jet lagged every day, I don’t even care about my patients any more. I know this isn’t safe- so I have handed in my notice. Jane has got a job in surgery in Vancouver, so we are out. Will it help the patients? No- but staying isn’t helping either. If they want to collapse the system, then it’s too late to do anything about.
If only we’d stopped this when we had the chance.
Juniordoctorblog.com