THE OFFER: Part 2- the Context

In a two-part behemoth post, juniordoctorblog examines first the contract, and then the wider context the contract sits in. This is Part 2: The Context of the NHS. Read Part 1 here

The contract does not sit in a bubble, and there are many nuances that require some background knowledge of how certain parts may or may not be used, now and in the future, and how that will affect junior doctors working in the wider NHS.

The past

Junior doctors in the NHS have had a rough decade. We took a huge £6000 paycut at F1 with the loss of accommodation, we had two pension raids meaning we pay in more and get less paid out (Remember this), and we had the debacle of MTAS. Since 2009 we have taken a further 25% paycut already due to the pay freeze against inflation.

The origins of this contract date back to a group of NHS executives who were desperate to take ‘advantage’ of what they saw as an ‘oversupply’ of doctors – creating a contract that cut weekend and unsocial hours pay and conditions worsened across the board. This is well covered here.

In the meantime the NHS budget has been essentially flat for the past six years, while assets have been sold off and social care and public health budgets have been slashed. £20 billion of cuts estimated between 2010-2015. Demand however has risen and risen. The wheels are starting to fall off.

In 2012 the Health and Social Care Act opened up NHS contracts to private companies, and devolved the duty of the Health Secretary to provide a comprehensive state-funded service. Private contracting has increased 500% in the last two years.

The present

Back to junior doctors – the contract dispute has left deep scars on our collective psyche. F1 applications for first preference to Scotland and Wales nearly doubled this year, and the programme as a whole was 300 doctors under recruited – the first time in history. The numbers of applicants from F2 going straight into speciality training also dropped at an unprecedented rate – 8% in the last three years. Certificates to work abroad have reached record highs – nearly 8000 since this all began, and whether any of those doctors will return remains to be seen.

Looking a little wider, vacancies for doctors have increased in the last year by 60%. Rota gaps are rife, especially in hard to recruit specialties like paediatrics. 1/3 GP posts is unfilled, 1/8 A&E posts, and 50-60% of registrars in A&E quit after 2-3 years of training.

Looking wider still, the NHS is in real trouble. This year the final deficit was £2.4 billion – a record. Hospitals were told by no.10 in the past two years to cut their regular staff budgets – this led hospitals to find themselves in situations where they couldn’t staff themselves properly, and therefore hired temporary staff at a greatly increased cost. A&E waiting times this year hit a record high, the worst since records begin. This has been the most austere decade in the history of the NHS.

And the government response? Jeremy Hunt, during this whole debacle, said at a speech this week the NHS needs to go on a ‘ten-year diet’. No more money is coming. Things will only get worse.

The future

Inflation is set to rise by 1-2.5% by 2020. The contract stipulates that our pay will rises by 1%, 0.9% then 0.8% in the following three years. This will be a continued paycut. But something more important is going on.

In the 2007/8 financial crash, the economies of most of the OECD crashed. A recent study in the Independent showed those countries without universal healthcare, where healthcare depended on employment and wages, had a cumulative ‘excess’ death rate from cancer totalling 260,000. Let me reiterate that – because of illegal and reckless banking practices, for which only one person was every prosecuted, nearly a quarter of a million people worldwide died that otherwise wouldn’t. Did that happen in the UK? No it didn’t – because of the NHS. Money in healthcare means lives.

Don Berwick, patient safety guru, has publicly said the NHS spend on GDP is ludicrously low. “I know of no modern healthcare country attempting to fund the NHS on 8% GDP, let alone 7 or even 6%.” That’s including the ‘£10 billion extra’ funds by the way. By 2020, with Jeremy Hunt’s ‘diet’, NHS spending could be as low as 6%. People will die.

Why does this matter? Because the context of the contract is one that will ultimately determine how it is used. We are about to enter a decade, without drastic intervention, where hospital managers and NHS will become increasingly desperate, as health inflation raises costs by 3-4% each year and the budget rises by 0.9% or less. This won’t be so much a ‘diet’ as death by starvation. The caveats in the contract that you’ve read and never imagined would be used now, may one day soon become the routine.

What will happen when you are working in a failing hospital, with spiralling deficits, no staff, desperate conditions? I’ve worked in a failing hospital before, and let me tell you, it’s terrifying. I’m not scaremongering here – I just want you to understand. We are building a ship to sail on incredibly stormy seas – it better be watertight.

Lastly, the spectre of privatisation marches onward. The Telegraph ran a rather stupid piece about it very recently – claiming that the lack of 24/7 on-site palliative care meant the NHS state-funded model is failing. Private companies are coming into the NHS at an increasing pace, and with no sign of funding to match the future we need to ask where the government plan to provide healthcare from?

The contract has many advantages to private companies.

  • Basic pay is pensionable – banding is not. If you look at the part 1 blog you will see that the pension contributions in the new contract are much larger than the old one. This means the pension pot for junior doctors is more profitable for those that own it.
  • Basic pay is paid for by Health Education England. Health Education England are due a £1.1 billion paycut next year- how will this help recruit more juniors? Or more importantly, train more nurses. Hospitals pay the supplemental fraction – as this goes down, it makes things cheaper.
  • Cheaper weekend work means more lucrative elective services 7 days a week, despite this being statistically less safe.
  • There are clauses in this contract that stop a junior doctor talking about their organisation unless there is some failure. Is this a soft gagging clause to prevent reporting privatisation?

Will this contract even last that long? In June this year Simon Stevens will divide the NHS into 44 individual ‘footprints’ responsible for their own budgets, this is the sustainability and transformation fund or STF. The ‘leaders’ of these footprints will be completely unaccountable for their actions – and with no planned increase in funding it won’t be long before whole areas are sold off to private companies, just to keep them afloat. What contracts will be agreed with these footprints or even the companies that come after remains to be seen.

And don’t forget the GP and the Consultant contracts, the Agenda for Change re-negotiations, the pharmacists and beyond.

Don’t think a Yes vote will mean you will be able to go back to your old job, go back to looking after patients and forget all of this mess. You will be going back into a greater and more dangerous mess than before, and it will require more effort, not less, to keep our profession from collapsing, to keep our hospitals from doing the same.

Don’t think a No vote will mean that we will go back to striking and protesting, eventually toppling the government and saving the NHS. The BMA agreed to these terms – it would create a gargantuan effort of hitherto unseen proportions to successfully campaign again against them. Not impossible. But extremely hard. And will it change what happens to the NHS? No one can deny this contract fight has politicized a generation of doctors, and ignited the issue of the wider NHS in the minds of the public. But a fight over a contract alone won’t help us.

I’m not going to tell you how I’m going to vote – mostly because I still haven’t made up my mind. We are handing some large levers of control to some people who are about to be very desperate indeed. Whichever way you vote, be prepared to continue to fight; for your working conditions, for your patients safety, for a free-at-the-point of service, world-class NHS.

Make up your own minds, pick your own battles, do what you have always done and do your best for your patient.

That is all I ask.

juniordoctorblog.com

 

 

 

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THE OFFER: Part 1- the Contract.

The decision to accept or reject these new terms and conditions is not only about the contract itself, but the context it sits in. In a two-part behemoth blog post juniordoctorblog looks first at the contract, and then the wider situation in the NHS.

Part 1: Let’s look at the contract. Read Part 2 here.

Unsafe?

There has been some movement between the March offer and the May offer on the safeguards for doctors working. The hours limits have been reduced, but realistically these are meaningless without a robust mechanism for enforcing them.

The new contract specifically removes ‘monitoring’, but more heavily involves the BMA/ local junior doctors in the process of ‘safeguarding’. This is a quick summary of the proposed new system for ‘breaches’ of hours.

  • The junior doctor reports a problem – this is called an ‘exception report’. This can be a problem about overworking on hours, or the post being inadequate training.
  • This ‘exception report’ goes to the junior doctors educational supervisor, with a copy to the guardian of safe working (see below) or to the director of medical education.
  • An initial meeting between the junior doctor and the educational supervisor occurs where the educational supervisor reviews the report and can remunerate the doctor, make changes to their rota or do nothing.
  • The junior can appeal up the chain – first to the guardian and DME and then to a panel – with the BMA or other sending a representative to sit on the panel.
  • The trust will collect data on rota gaps and report this to the GMC, HEE, and GDC. A copy should go to the junior doctors forum
  • The junior doctors forum will be formed by each DME and ‘advise’ the guardian on spending of funds produced from penalty fees paid to doctors who are overworked. The exact split of how much will be paid to the doctor and how much to the hospital is TBC

Here is a diagram from the BMA that outlines this process.

Hours diagram

I have a number of issues with this system

  • The process from first reporting to sitting before a panel if an exception report is not dealt with properly is approximately 16.5 weeks at a maximum. That’s through every level of escalation. Seeing as how most placements last 4 months, and the doctor isn’t going to report on day one, this seems wholly unfit for purpose
  • The process puts a huge onus of responsibility on the educational supervisor, assuming powers that they certainly do not have currently, namely;
    • The power to create ‘learning opportunities’ in a work schedule. Imagine an ITU consultant ‘creating’ a clinic for a trainee to sit in, or an Oncology consultant ‘creating’ a procedures list.
    • The power to give time off in lieu or renumeration – mostly ES don’t work in dept or with rota managers, let alone HR – so how will this work?
    • The power to remove doctors from posts and initiate system-wide changes, especially as “The educational supervisor may be in a different department, and occasionally in a different organisation, to the trainee”
  • The final decision on an ‘overworked’ doctor is ‘final’ at the panel
  • ‘Breaks’ – have to be taken at approx 30 minutes/5 hours or 2x 30 minutes in 9 hours. ‘Breaches’ related to missing breaks are to be ‘validated and found to be correct’ before any action will be taken. 1) Who covers during a break? Most shifts I’ve worked have been the bare minimum staff, so what is the arrangement to have a break? 2) Who is going to validate and find this correct? 3) Is it a ‘break’ when you are carrying a bleep?
  • Overnight rules regarding rest are welcome – if <5 hours rest or working continuously when on-call the doctor is ‘exempt’ from the next days work. But there is no provision in the contract for anyone to cover. How do you go home as the surgical registrar for example on a saturday after on-call if there is no surgical registrar covering?
  • The involvement of junior doctors in the running of their training is a good thing – but what is to stop them being sidelined in hospital? To my reading there are no mandated reporting of the guardian to the JD forum, no powers to stop a guardian appointee missing meetings and not engaging. Will this work in smaller trusts?
  • The entire removal of ‘hours monitoring’ is still the worst thing about this contract. But there may be a solution – see below.
  • There are many references to doctors being asked to make emergency cover arrangements, exceptional circumstances to cover rota gaps and accrual of ‘time in lieu’. Looking at the context (See linked post- Part 2) of the contract, I worry these are all clauses that will enable hospitals to stretch their workforces far farther than was previously safe. Despite the assurances that ‘breach’ penalties will be paid – the money now goes back to the hospital. This effectively removes any actual financial penalty to the hospital, and remains cheaper than hiring more substantive staff or hiring locums. In times of austerity I am concerned this will lead to hospitals relying on their juniors to plug gaps. But more on this in Part 2.
  • The guardian role. I have many issues with this;
    • The time commitment is ‘dependent on the size of the organisation’ but a singe guardian can still cover multiple trust sites. There needs to be a maximum number of trainees/guardian, the role has to be full time (previously advertised at 1-2 PA’s a week, equivalent to 4-8 hours work for a consultant), and must be completely independent from the board and HEE. Only independence is stipulated in the contract so far.
    • ‘Funds’ distributed from ‘penalties’ can go to ‘expertise in rota design’ and ‘service improvement projects’. There is nothing stopping trusts taking ‘penalty’ money from overworking doctors and funding more HR staff, or a ‘service improvement’ project unrelated to junior doctors conditions e.g. repainting A&E.
    • ‘Work schedule reviews’ are triggered when the trainee believes the rota breaches the contract hours. How a guardian, who will be a senior consultant most likely in an unrelated specialty, will change rota’d hours and work commitments in another specialty seems practically very dubious.

Overall on safety I welcome the headway that has been made on what was a travesty of a contract in March, but I still think it doesn’t go nearly far enough, facing the crisis the NHS is heading towards.

Unfair?

On equality – the contract makes some important in-roads

  • The Guardian is seconded to ensure equality and diversity are respected, and that a ‘champion of flexible working’ is appointed within the educational faculty
  • HEE have promised to make a review into married couples and civil partnerships, and those with caring responsibilities, to make joint applications or transfer between regions more easily. This is supposed to happen next year. We will have to watch this very closely.
  • Transferring specialties for those with disabilities or care responsibilities will attract pay protection.
  • The flat nodal pay structure doesn’t disadvantage women on maternity in registrar training
  • Additional proposed steps for women re-entering training from maternity, or academics returning to training receiving flexible pay premia.
  • Pay protection until 2022 will mean those in registrar training now will not lose out, even if they take further time out e.g. for maternity or academia
  • Changing specialties may be further improved by a ‘mutual curriculum’ recognition programme to review next year

There are still issues here;

  • Non-resident on-call pay allowance is proportional to the amount of time spent in work. This means that two junior doctors are paid at different rates for the same work. That is not acceptable.
  • If you are non-resident but feel that going home is unsafe, the hospital will charge you for on-site accommodation, therefore you will be paying the hospital to work for them. At LTFT rates this will actually cost a significant sum per hour.

On pay

This is the most complicated part of the contract, and it’s complicated by the fact that we as a profession all work very different rotas, with different time commitments, on-call arrangements and duties, plus the point at which they are now in training. Johann has posted this cumulative comparison chart – both general and per specialties to review.

chart

 

I still propose that everybody works out for themselves exactly their own earnings over their training lifetime – e.g. from F1 to ST8 or whichever, on both the old rates and the proposed contract. Remember to exclude NI (now 12%), pension pay (which is removed from your basic ONLY), and tax.

Here is a complex calculation I did – based on a medical rota of 40% 1B banding;

Night rotas

As you can see the lifetime take-home pay for a 40% 1B banding on the old rota, compared to a 1 in 6 weekends, 1 in 6 nights rota (4 nights every 6 weeks at 12/hr per night), is a very slight pay rise, over 10 years of training, of around £600/year. However on a 50% 1A banded rota, roughly 1 in 4 weekends, 1 in 4 nights rota (again 4 nights, 12hrs/shift, every 4 weeks e.g. typical ICU) it’s a slight pay increase, £300 per year take home pay. So while the ‘basic payrise’ disappears in take home pay, it does increase your pension however, I have yet to calculate exactly by how much. Whether or not this is acceptable to you is a personal opinion.

(Please post your individual calculations in the comments below with the conditions and your working, so we can get a collective sense of how everyone will be affected. Remember your vote is for yourself, but also for your colleagues.)

The real issue here is how out-of-hours work scales – the pay difference between a 1 in 4 weekends, 1 in 4 nights vs a 1 in 2 weekends, 1 in 4 nights, over your lifetime is about £500/yr. As in for working twice the weekends you were previously (and for work the definition is any hour worked on the weekend), you will be paid roughly an extra £60/month. That won’t really cover twice as much childcare for example. As pointed out previously, ‘acute’ specialties will lose out the most.

Inflation:

  • It’s important to remember that with the pay freeze since 2009 Junior Doctors have lost 25% of their income.
  • With further below inflation pay rises we stand to continue receiving this stealth pay cuts: 1%, 0.9% and 0.8% over the next three years, with inflation predicted to rise between 1-2.5% by 2020.

This doesn’t take into account non-resident on-call or flexible pay premia pay.

  • On NROC I see two main issues.
    • The ‘prospective’ average estimate is not going to actually work – shifts will vary wildly between having to be ‘at work’ and not, depending on several factors, some of them dependent on the individual doctor. The contract is very specific; ‘work’ is any clinical work, including telephone calls.
    • I can imagine pressures on judgement for doctors that preferred to ‘go in’, if they are outliers in a rota where most people don’t. This creates a mechanism for monetary considerations in clinical judgement. I find this unacceptable.
    • Again, the 8% on-call allowance is acceptable, as long as work done on-call is paid for at the prevailing rate, and it is still safe to regularly work the next day. This will take exceptional vigilance on behalf of individual trainees- more on that below. Again this will be overseen by educational supervisors and guardians of unsafe working.
  • On flexible pay premia; for academics this is good, and for hard-to-fill specialties this may be good, although I imagine the amounts spread over training and subject to tax would make very little difference to take-home pay on a monthly basis, especially in hyper acute specialties already losing out on unsocial hours like A&E.
  • Pay protection is rubbish. Please do not rely on this. The ‘cash floor’ is created by your earnings plus allowances on 31 October 2015 or 2 August 2016. This does not take into account the rise in salary you would be due if you weren’t on the new contract, and only protects your basic. Allowances for weekend and unsocial hours are calculated on your new basic, in the same way.
  • Locum work: this is going to be a disaster. The assumption is the majority of us are in training and doing sneaky extortionate locum work through agencies. Forcing us to work through a staff-bank for shifts isn’t going to change a thing. Why?
    • 1) Most full-time trainees cannot safely do agency locum work on top of their existing training commitments. I have probably done maybe 5 locum shifts in my career.
    • 2) Most agency locum doctors are not in training- therefore unencumbered by these clauses anyway
    • 3) Even if the odd shift we work on top of training was covered as an NHS bank instead of as agency bank, it would still leave the majority unfilled. Usually this worsens cover for substantive trainees, making conditions harder and dangerous.
    • 4) It’s also unnecessarily punitive, and generally annoys people to think that a contract can monopolise their personal time as well as the time they spend at work.
    • 5) I suspect this will actually diminish the part-time locum market, making posts harder to fill.
  • Again this comes down to the context of the NHS right now – see Part 2 of this linked post.
  • Pay for work done. Through the guardian system you will need to be ‘authorised’ for additional hours, either before, during or sometimes after the hours worked, if you want to be paid for them. This does not reflect our usual working practices, and the contracts refers us to our ‘manager’. I have never really known who my ‘manager’ is, and as for staying late it’s always been for emergencies, when seeking authorization is not practical or safe. Again any monetary concern interfering with clinical practice is unacceptable.
  • There might be ways to sort this – but it would need to have a clearly defined ‘manager’ who is reachable 24/7, and routine acceptance of ‘after-action’ authorisations for additional hours. I can already foresee this falling apart instantly.

Overall on pay I think most people will see no difference in pay, if they stay on current rotas. However, with the proposed rotas yet to be seen, you will see a substantial drop in pay for increased unsocial hours that you would’ve previously received. If your rota goes from 1 in 4, to 1 in 2 weekends, you will be paid pretty much the same. I’m happy to be corrected on this by anyone who sees flaws here – this will need to be a collaborative effort to try to ascertain the impact the contract will have.

What else?

  • There is a clause in the contract saying HEE actions are subject to reporting ‘without detriment’ to the individual junior doctor. This is regards to the Chris Day case – I have spoken with Chris and he doesn’t trust a contract clause like this to actually stand up in law. It needs a law change to back it, to protect trainees like Chris.
  • Leave is only allowed during ‘non-enhanced hours’ work – which now means only between 0700-2100 and no weekends. This isn’t dissimilar to current arrangements, but if rotas increase out of hours unsocial work then actually swapping to arrange leave will be difficult.

 

Summary

Overall I think it comes down to trust. Do you trust your hospital and your bosses to be able to implement this contract without compromising your safe working, and to listen to your concerns if it does? Do you trust your hospital and it’s managers to honour its agreement on pay for work done, and to not create rotas which are punitive and cover a lot of excess unsocial hours? Do you trust your hospital and your health secretary to listen to your concerns when the contract is reviewed in March 2018?

This is a comprehensive FAQ from the BMA : https://www.bma.org.uk/collective-voice/influence/key-negotiations/terms-and-conditions/junior-doctor-contract-negotiations/new-contract-faqs

Think on this carefully. Then think on your vote; remember the ‘referendum’ will only guide the JDC, so if it’s close it will be far more difficult than if it is clear-cut.

This won’t be a simple vote on whether you find this contract acceptable or not. Both options will require ongoing action to ensure that the terms and conditions don’t simply slide back without our input.

If you vote yes;

  • We will need a system to accurately monitor hours, to ensure not only that you are paid for work as you are supposed to be, but that hospitals are running safely, and not overstretching doctors. Without formal hours monitoring we will need to provide hard evidence, that is easy to record and easy to generate, that we need more doctors.
  • We will need to take an active part in our hospitals, ensuring that the LNC is a visible entity, with real power and real support. We must be prepared to escalate and see through proceedings about breaches and training
  • We must ask for reassurances that educational supervisors will evolve into the super-entities that this contract requires -that they will have power to actually do what the contract suggests they can do
  • We will have to be vigilant that the contract is implemented respectfully and honestly, and report incidences where it is not – to both the local LNC and the BMA and wider community.
  • We must no longer isolate ourselves if we hope to survive as a profession – don’t leave that Facebook forum even if you really want to.

If you vote No;

  • We must think about what comes next – what do you want to see, and how do you want it to be achieved?
  • Are you prepared to re-escalate strikes? To resign?
  • We must recognise that a close vote will mean the government will accept the contract on behalf of the minority ‘Yes’. They want this to go away, and don’t wish to concede any further.
  • We must recognise the ‘context’ of this contract. Will a No vote lead to benefits in the long-term? What would the junior doctor workforce look like in the future?

Now read Part 2 – the Context. Before you decide.

 

juniordoctorblog.com

 

Do Not Attempt Resuscitation: let’s have a conversation

One of the hardest parts of any doctors job is talking to patients about the end of life, and whether to try to resuscitate them or not. I often wish I could have these conversations far away in space and time from the moment a patient is actually ill.
So let’s talk about it now. 
When I sit down with a patient or their family to discuss resuscitation I always find their understanding of CPR very different from mine. We always start with the same questions.

What is CPR? It stands for cardiopulmonary resuscitation, which simply means, trying to restart (resuscitation) your heart (cardio) or lungs (pulmonary).

Which simply means if you get so sick that your heart or your lungs stopped working, we would try to restart them. 

How do we do that? Well, the process of CPR is actually quite brutal. To pump a heart that isn’t beating you have to compress it from the outside, 100-120 times a minute. To do it properly you need to squeeze the chest by 1/3 of its depth, or 5-6 cm deep. 

This sometimes breaks ribs. Trust me, it’s as horrific as it sounds. 

The next step is stripping the clothes, and placing two large electrodes on to the chest connected to a monitor and large battery that can give an electric shock. If there is a heart rhythm that can be shocked, we dial up the machine to a high energy setting, tell everyone to not touch the patient or they will get shocked themselves, and electrocute them. I’ve seen this in semi-conscious patients and it hurts. 

We then carry on with pounding on the chest. 

At some point a specially trained doctor or nurse will try and pass a breathing tube into your throat, insert tubes into the veins in your arms, neck or groin, and give large doses of heart pumping drugs. 

We cycle through this process, deciding every two minutes whether the heart can be shocked, or whether there is something else we can do. This can go on for sometime- we swap the person giving compressions back and forth so they don’t get tired. We even have a machine that does this for us.

At some point we will have tried everything. Resuscitation stops when every single member of the team agrees there is nothing more to do, or the patient’s heart will start beating again on their own.

What happens next? If the patients heart or lungs started working again, then the breathing tube is connected to a machine, and the patient is taken to intensive care.

I’ve looked after lots of patients who went through this, what we call a ‘cardiac arrest’. Some will leave the hospital, many won’t. 

The reason being is that for every second your brain is without oxygen, your brain cells are dying. We can see this on an MRI scan after a long period of ‘downtime’- time without oxygen or blood pumping leaves your brain swollen and misshapen. The chance of recovery is slimmer the worse the damage appears to be.

That all sounds very doom and gloom, but it shouldn’t. This is the very last ditch attempt to save life, and its value is inherent in the few successes we have. But they are few.

I wish everybody knew how few. The problem is our understanding of CPR as a society is based entirely on commercials and television.

A large study many years ago found that on television nearly 70% of resuscitation scenarios end with the patient waking up, and hurrahs all round. But this is far from reality. 

In the average person, the chance of that patient waking up and leaving hospital after a ‘cardiac arrest’ is around 18%. In patients with severe medical conditions, such as stroke, sepsis, or failing heart valves, the chance is about 5-10%. In end stage kidney disease or end stage cancer it can be as low as 1%. 

That is probably news to you. It certainly was to me at med school. It’s news to most of my patients and their families. 

So in summary, CPR is a brutal last ditch process that seldom works and usually has significant and lasting harms for the few that do survive. You may think I’m being grim, but this is the honest truth- please ask any medical professional. 

Now that’s why I always want to talk about CPR when people are well. When things are very hectic and somebody is very sick, it’s very hard to listen to someone saying the chance of success of CPR is low- it sounds like we are giving up. 

But we are not, we are making a plan. Good doctors like plans. We call this plan a ‘do not attempt CPR’ order, or DNACPR. It’s a very important bit of paper, kept at the front of the patients notes, usually an obvious colour like red, that states very clearly that if heart or lungs stop working we should not try to restart them, and the reasons why. 

It doesn’t change any decision about having an operation, or chemotherapy, or even using life support machines. It’s not about changing the course of treatment, it’s about making a plan for if it all goes wrong.

It might surprise you to know that a higher proportion of doctors who become unwell choose to not be resuscitated and decline treatment than the general population , choosing to die at home rather than hospital. Many doctors have their red line conditions, things they have seen that they themselves would never want to go through the treatment for, knowing the suffering involved and the likely outcomes. 

There’s a great book about medicine and death called “Being Mortal” by an American surgeon called Atul Gawande. In it he talks about five questions that everybody should ask when they contemplate the end of their lives, and he sums them up with one question “what are you fighting for?”

Reading this at home, hopefully very well, it might be hard to ever imagine what you would want if you became very sick. What would you fight for? Please think about it. 

We aren’t very good as a society about talking about death, as if the discussion of the inevitable somehow diminishes the possible. Normally my blogs finish on an abrupt punchy ending sentence, but I find the hardest conversation in my job never really ends, it just moves on,

Juniordoctorblog.com

References

Decisions relating to cardiopulmonary resuscitation 

https://www.resus.org.uk/_resources/assets/attachment/full/0/838.pdf

What Are the Chances a Hospitalized Patient Will Survive In-Hospital Arrest?

http://www.the-hospitalist.org/article/what-are-the-chances-a-hospitalized-patient-will-survive-in-hospital-arrest/

Being Mortal by Atul Gawande

Cardiopulmonary resuscitation on television. Miracles and misinformation.

http://www.ncbi.nlm.nih.gov/m/pubmed/8628340/?i=3&from=/19699021/related

Nolan et al “Incidence and outcome of in-hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit.” Resuscitation. 2014 Aug;85(8):987-92.

http://www.resuscitationjournal.com/article/S0300-9572(14)00469-9/fulltext

The Significant Seven: an Exploration of the Counter-Evidence for a ‘7-Day NHS’

The Department of Health’s favourite line is “There are 8 independent studies showing a ‘weekend effect'”. I’ve been through these 8 before, and the terms “independent” and even “studies” are used fairly loosely. This has been the stick Jeremy Hunt and co have used to justify their unfunded and unmodelled 7-day NHS plans, and to beat the junior doctors with. This week the stick broke.

To borrow the Ministry of Truth’s own language: “There are now 7 independent studies showing that the 7-Day NHS plan is a bad idea”.
Juniordoctorblog explores the counter-evidence against the 7-day NHS spin.


The ‘Weekend Effect’

Three separate studies this week came out against the established narrative of ‘poor care’ at weekends creating excess deaths.

“Higher mortality rates amongst emergency patients admitted to hospital at weekends reflect a lower probability of admission” by Meacock et al in 2016

All previous research has shown increased rates of dying amongst patients who are admitted to hospital at weekends, but not those already in hospital or attending A&E. Meacock et al used the same data from the original Freemantle paper that Jeremy Hunt was quoting his ‘11,000’ excess deaths figure from, which covered 12,000,000 admissions to all 140 hospitals between 2013-14. They found for patients attending A&E on the weekend, far fewer were being admitted to hospital vs a weekday. When you look at all patients attending A&E, as opposed to those being admitted, there is no weekend effect. The authors attributed this to the differential admission threshold – well patients are less likely to be admitted on a weekend, so this makes the group admitted on weekends sicker on average, thus increasing mortality rates slightly.

Bottom line: the ‘weekend effect’ appears to be about how patients are counted, not how they are looked after.

Professor Rothwell, Oxford University, interview on Radio 4
– so far, unpublished study

Now the purists amongst you will claim this is unpublished, and therefore not available to scrutiny. I agree. However, we are using the DoH definition of ‘study’, which includes all manner of reports, audits, and human resources documents. So it’s in the Seven.

Prof Rothwell group based from Oxford Univeristy found similar problems with the ‘weekend effect’ amongst stroke patients. Looking at patients in Oxford, they found those labelled ‘strokes’ weren’t strokes at all, but were admitted for other things, like urgent investigations, or rehabilitation. These admissions happened primarily on weekdays- meaning only truly sick stroke patients came on weekends, but weekdays had a mix of very well patients and unwell patients. Once these was corrected, the weekend effect disappeared. Prof Rothwell said “nobody had done… the basic due diligence” on these studies to look at this.
Bottom line: the weekend effect again was found to be a statistical artifact, based on how patients are counted, not how they are cared for.

“Weekly variation in health-care quality by day and time of admission: a nationwide, registry-based, prospective cohort study of acute stroke care” by Bray, 2016

There were a lot of statements about stroke care, and a huge backlash from stroke experts who had already spent 10 years improving the urgent care of stroke. Now a new study from Bray that used national data between 2013-14 on 74,000 patients with stroke found no association with weekend vs weekday admission. No weekend effect. It did find variation across many variables in different patterns, including a small increase in mortality in weekday night admissions. The study called the weekend effect ‘an oversimplification’.
Bottom line: Again, no weekend effect, small changes on weekday nights, and further work needed. Oversimplification not helpful.

“What are the Costs and Benefits of Providing Comprehensive Seven-day Services for Emergency Hospital Admissions?” by Meacock in 2015

Put aside the fact for a moment that the ‘weekend effect’ probably doesn’t exist. Don’t get bogged down in methodology, as Jeremy Hunt doesn’t. This paper by Meacock in 2015 looked at the actual size of the supposed ‘weekend effect’ and then worked out the cost to address it. It found the cost, £1-£1.5 billion, was far higher for the small supposed benefit than any medication or treatment recommended in the NHS.
Bottom line: even if the ‘effect’ existed, the money would be spent better elsewhere for greater patient benefit.

“The 7-Day NHS”

So despite the evidence being weak, the government has plowed forward in making their “7-day NHS” plans. Except they haven’t.

“Managing the supply of NHS clinical staff in England”
Public Accounts Committee 2016 

The PAC is a group of MPs that examine public policy and hold public departments to account for their decisions. This report found that the Department of Health had made ‘no coherent attempt’ to work out how much a 7-day NHS would actually cost, or the doctors or nurses needed to staff it. They were told they were ‘flying blind’ on this issue. A leaked report suggested they needed £1 billion a year, 4000 more doctors, and it ‘probably wouldn’t alter’ the supposed weekend effect anyway. They also found that the NHS has been cut by 50,000 clinical staff.

Bottom line: close scrutiny of policy for 7-day working found it to be woefully lacking. 

While the 7-day policy seems to be a shambles, a further report shows the existing NHS  heading to disaster;

“Sustainability and financial performance of acute hospital trusts”
Public Accounts Committee 2015-16

This second public accounts committee focuses on hospitals and funding. It revealed that No. 10 created “unrealistic” and “unsustainable” budget cuts to hospitals. As in the report above, hospitals had to cut regular staff but many refused to cut quality in favour of cost- hiring back temporary staff at a higher rate. The committee were clear that the excess cost running the NHS into a deficit of £2.8 billion was 80% due to the gaps created, not the fees themselves. The report also found dodgy accounting practices – which came from a whistleblowing hospital accountant who requested anonymity for fear of losing his job. It would seem a lot of ‘creative accountancy’ was going on to make hospital budgets look healthier than they are, to cover up the extent of the ‘black hole’ in NHS finances.

Bottom line: NHS hospitals are currently in a budget and staffing crisis created by No. 10 who then attempted to cover it up. 


Still with us?

So far we’ve established that the 7-day NHS is an unfunded and unmodelled solution to a non-existent problem, which probably isn’t fixable itself, but even if it was, isn’t cost effective to do so. Meanwhile the real problems of the NHS are not only being unaddressed they are being actively covered up.

So what’s it all about then?

Throughout this drive for seven days services has been this narrative that their aren’t enough doctors at weekends, and this leads to harm; the ‘weekend effect’.
So having already discussed there is no weekend effect, we should probably still address this ‘lack of doctors’.
Firstly, no study has ever looked at junior doctor staffing levels. Full stop. So we actually cannot possibly say that is associated. One study from the Hateful Eight actually showed that medical cover is 100% across seven days, and this is true, all hospitals have junior doctors Monday to Sunday, midnight to midnight. Despite this Jeremy Hunt embarked on a damaging junior contract fight anyway, despite all the evidence to the contrary.

What’s surprising is that the Department of Health themselves don’t even know how many juniors are already working weekends.
Freedom of Information Request to Department of Health 2016 and Commons Question, 2016

In two unrelated freedom of information releases NHS England first revealed they had no idea how many junior doctors typically work on a Saturday or bank holiday nationally, and then in a written question from MP Norman Lamb it transpired that the only research into this that had been done was a ‘snapshot’ of 14 hospital rotas, in January 2016 (well after the contract had already been ‘imposed’, I might add).

Bottom line: despite no evidence to show a link to junior doctors and weekend mortality issues, a new contract was ‘imposed’ anyway, without anyone actually studying the problem they were trying to ‘fix’.

Confronted with this last week, the Department of Health shifted the goalposts once again– now saying the ‘weekend effect’ is about consultant presence and diagnostics. Except it isn’t.

“Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study” by Aldridge in 2016

This is a study looking at a snapshot of weekday to weekend cover of consultant specialists attending hospital admissions. It found that consultant specialist presence varied between weekend and weekdays, but found no link to any change in mortality.

This follows from another study by Bray in 2014 looking in stroke units specifically whether the presence of a consultant on weekends and weekdays made a difference to mortality. In that study consultant presence made no difference, but the number of nurses had a direct link to survival.

Bottom line: in the only study that looked at weekend and weekday mortality in NHS hospitals there is no link to consultant presence. 

Nursing numbers are much more important but this government cut training places in 2011 and cut the bursary in 2016- the PAC recognised this would continue the shortage for at least another three years. 

Wrong again.

 The Significant Seven are a damning group of ‘studies’ that highlight how ill thought out and potentially dangerous both the 7-Day initiative and the current NHS management is. Is this incompetence or something else?


Let’s change the perspective.

Imagine you are in government. You made a back of the envelope promise of a ‘7-Day’ NHS without defining anything for voters, but you’re also ideologically against increasing funds to a socialist medical system.

You can’t be seen to cut costs to a beloved and vital national institution, so you announce ‘efficiency’ drives and streamlining of services, a ‘pay freeze’ which cuts pay by 25% against inflation. You get wind of new NHS contracts, and decide to make some subtle changes- increase basic pension contribution, reduce junior doctors pay and remove financial penalties for hospitals that make doctors work illegal and unsafe hours.

Obviously you can’t be seen to want to attack doctors to cut costs, you need a PR message that will travel. You find an already running plan to improve urgent 7-day Care, and in the words of Fiona Godlee, editor of the BMJ, derail it.
You never really believed hospitals needed that much money, or that costs really do rise at that rate, so when hospitals started to report crisis level failings, you didn’t listen. When junior doctors protested and demonstrated and even sat outside your office for three weeks, you still didn’t listen.

I am a doctor- I want a 7-day health service more than anyone, because I know what that would really mean. I also know that we need more funds just to keep the staff and the hospitals we have already going, and if we want to ever improve our health service, Mr Hunt, we must use the evidence properly.

Now the evidence is knocking on your door.

It’s The Significant Seven , and behind them 68 million people. We’d all like a word about our national health service. It’s time to listen.

Juniordoctorblog.com

Jeremy. Let’s make this simple. 

“Everything should be made as simple as possible but not simpler.”

Albert Einstein

There’s a great book called Thing Explainer by Randall Munroe that explains lots of complex stuff in the simplest terms possible, using only the thousand commonest words in the English language. The dispute over the new junior doctor contract has become increasingly confusing, so let’s keep this really simple.


Jeremy Hunt said this new deal for doctors was meant to make ‘7 Day hospitals‘. He said ‘more people die on Sunday compared with Wednesday‘ and this is because of poor care and less doctors. He called this a ‘weekend effect’. The papers where we read about new events said this too, many times.
But new findings show there is no ‘weekend effect’. People sick at weekends go to hospital, but fewer people actually stay in hospital at weekends, and less people die, not more, on Saturday or Sunday. Only very sick people stay in hospital on weekends, while slightly less unwell people go home and come back during the week.

It is easier to explain if you use a story.

Here is a story.

Ten people go to hospital on Wednesday, two are very sick and will soon die, two are well but need urgent advice. All ten stay in hospital, and the two who need advice are seen by a special doctor who gives it to them. For that Wednesday ten people stayed in hospital, two people died, so the ‘risk’ of death is 2 in 10, which is 20%.

The same ten people go to hospital on Sunday. Two are very sick and will shortly die, two are very well but need urgent advice. The two who need advice see a general doctor, who arranges a special doctor to see them on Monday. They go home. The eight left stay in hospital. For that Sunday eight people stayed in hospital, two people still died, so the ‘risk’ of death is 2 in 8, which is 25%.

So because two well patients waited at home for advice, instead of staying in hospital, the ‘risk’ of dying on Sunday seemed to go up, by 5%, because of how they were counted, not because of how they were looked after.
So Jeremy Hunt said we need to make 7 day hospitals. We have ‘7 day emergency hospitals’ and we know now that those 7-days look after emergencies the same, every day.
Doctors don’t like the ‘new deal’ because it’s unfair to women, reduces pay, and spreads five days worth of doctors across seven days, for what we now know is no good reason. It also takes away the rules that stopped hospitals making doctors work unsafe hours. 
Doctors told Jeremy Hunt this was a bad idea, but he forced the deal on them anyway. Jeremy Hunt told doctors they were killing patients by not agreeing to the new deal. This was a lie, and it made doctors sad. Many have now left.
Now Jeremy Hunt wants to talk again, but only about Saturday pay. Doctors know this was never about Saturdays, and now so do you. Jeremy Hunt told everyone that the new deal wouldn’t cost any more money than the old deal. So without a reason to change things, what does Jeremy want?
I’ll tell you what I want. I want to go back to looking after people again. I want to go to work and have enough doctors to look after everyone properly, every day. I want hospitals to have enough money to help us do that. I want the people in charge to only want that too. I simply want hospitals that continue to look after everyone based on need, not on how rich they are.

Now that you’re up to speed, what do you want?
Juniordoctorblog.com

Topple the government? It think it’s called democracy. 

Today is an Election Day. Many of you don’t vote in local elections, I certainly didn’t. You might not think it’s important, but this is the only language politicians understand.
You might not think that who sits on your local council doesn’t matter. You might even think who sits in your mayoral office isn’t important. If you do, then whoever sits in those offices of power thinks you are inconsequential too. You play no part in the democratic process, so you have no voice. So what’s important to you doesn’t matter to them, your concerns, dreams, fears for the future, are not theirs. They will only care about a future built on votes, should only make decisions based on their voters. 

I’ll freely admit, it’s closer to broken than perfection. Churchill called democracy the ‘least worst form of government’. 

During the last junior doctor strike the BBC and right wing press ran a story saying the BMA were planning to ‘topple the government.‘ This hilarious piece was quoted as from a ‘government source’. It was quite rightly dismissed as bollocks by all doctors. This dispute isn’t about politics, it’s about patients. As soon as the government realise that we might be able to start again.

But what if it was? What if, the 58% of the public that support the junior doctor strikes, made a decision about the local and national government they want to run their NHS. To run their schools, to train their nurses. What if they made that decision manifest in their vote?

At some point in our collective national past every single one of us, shamefully, would not have been eligible to vote. From the days of King and Pope, to the common vote, to the suffragettes, to race equality, people have suffered, struggled and died for your right to vote today. Don’t waste it.

I’m not advocating any party. I believe every individual has the capacity to make a decision about the democracy we live in. Whether you wish to ‘topple the government’ or support it, your vote today is the single most important determining factor you have in the direction our society goes. 

Whatever you decide today, go and VOTE.

Polling is open 7am-10pm.
Juniordoctorblog.com