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