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

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5 Comments

  1. Is it the Conservative dream to “make NHS care the safest and highest quality in the world”? I thought that’s what the NHS was already striving for, irrespective of which political party is in power this week. And that by some measures, we might already be achieving this. I wonder how Jeremy will know where the NHS ranks in terms of quality and safey; what are his outcome measures? Or is his vagueness deliberate, so as to fit available evidence to his chosen argument when the time is right?

  2. I’m old enough to remember several government vs BMA disputes and they all boil down to government wanting reform/ more efficiency and the BMA/ doctors wanting the status quo and more money. Well right now there is no more money; in fact we are borrowing billions and cannot really afford the current, let alone increased, levels of NHS funding.
    On Saturday pay all Hunt is trying to do is remove perverse incentives for hospitals employ more staff in the week vs the weekend than they would otherwise do. Perfectly sensible. Rotas are set by hospitals not the DOH. If hospitals want to keep the same rotas as before they can. New contract does not determine rotas.
    Finally you are a junior doctor; I’m guessing you have never run much more than a bath. Why do you think you have the answers to running the largest organisation in the UK?

    1. Some interesting points David…

      It’s ironic that David is ‘guessing’ about the author’s ability to run a ‘bath’ As if discrediting him/her makes a point. I’m not an electrician however, I know when the light isn’t working! In fact like JHUNT, guessing seems to be all that’s happening. People seem to be terrified of operating in a deficit. It’s actually quite viable and sensible for governments to operate in the aforementioned. especially with the current interest rates.
      How have we as a society, got to a place where we’re so afraid of national debt that it becomes conceivable to call doctors greedy for wanting fair pay and conditions. Conditions that don’t discriminate against gender and allow some form of work life balance. Removing safeguards to save money and replacing them with the token ‘guardians’ who work less hours per week than an ugly scarf you were given at Christmas is disgraceful. These are after all, the people that spend longer at university, have more debt and work ridiculous hours already to keep us safe.

      The misrepresentation of facts by this government in order to justify this cost cutting exercise is beyond a joke…funding a health service with under 8% of GDP is begging for it to collapse. You David, may think it is reasonable to sacrifice the morale and working conditions of doctors in order to save a few pounds but the majority of us do not. The most of us value the NHS being free at the point of delivery. While I suspect, you David, would be able to afford healthcare in a private insurance based system…there are many that won’t.

      There may come a time where your memory of previous government vs union battles is not as clear as it once was, a surplus will not diagnose nor prescribe when you need it. Many public sector professions have been hit hard recently and non of these examples are a justification to hit one more. Having said that, efficiency savings could be made to politicians wages and conditions as their mismanagement and waste is at an all time high. Maybe then we would have ‘more money’ to fund a service we all use and rely on, on our worse day.

  3. Let’s face it you have had 73 out of 75 points conceded and all that’s left is wrangling about Saturday pay rates. Now don’t tell me ii’s not about the money because that’s what you’re arguing about. You’ve already had hours guaranteed to be reduced down to more achievable levels compared to junior doctors who routinely worked 90+ hours per week as a consultant anaesthetist to my knowledge did when he was in your position. This smacks of BMA playing politics and smearing Jeremy Hunt to gain them more power and advantage over public funds which are in rather short supply. Other professionals work long hours and receive their standard salary in the knowledge that in the long run they will earn much more and be able to reduce hours. To that extent junior doctors and the BMA are exhibiting unprofessional attitudes and actions including striking.

  4. Mr Ricardo and Mr Moonie make valid points but they have been swayed by the rhetoric. It is beautiful & ironic how ‘babyboomers’ are arguably the most keen participants in ‘intergenerational conflict’. [David Willets has written a little on the topic] Is this a reaction to what Nu Labor & the neo-liberal elite did to the private sector pensions or is it just “grumpy old man syndrome”…?! Babyboomers should bless the day they were born. No one under 40 will ever enjoy the benefits and privileges that this particular generation received & still receive. What junior doctors earn has very little to do with the government’s overarching plans for healthcare. For anyone with secondary school education it is obvious that 54,000 relatively “junior” people are not that significant to the public finances. Running healthcare expenditure down below 9% of GDP whilst the vast majority of G20 nations have increased their expenditure or held it steady is a recipe for chaos. Dropping expenditure to <8% of GDP as HMG have planned whilst maintaining high immigration and having one of the highest birthrates of developed nations is deliberate destruction or f*****g ignorance! The BMA is a 'union' so by definition it represents the interests of doctors. Doh..! However their dispute with HMG over working hours regulations is being used as a Trojan horse to fragment the medical profession and coerce doctors into legitimising privatisation. The benefit to politicians will be an increase in their personal wealth(via consultancy, directorships and lobbying). There will be even fewer doctors working longer hours in both public and private sectors. So they will be demanding even higher salaries to cover their training, revalidation and insurance costs. Shareholders of private sector stakeholders will need to take their cut too. So the ordinary tax payer will lose out on what HMG can purchase. Furthermore those on middle incomes will have to sacrifice even more income just to top up on what HMG fails to provide. Disaster beckons….

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