If you want an NHS, save it yourself

It was July last year that something changed- Jeremy Hunt took to the podium and started a fight, claiming doctors had a 9-5 attitude, attacking our professionalism. But that fight was just a scuffle in a longer battle for a free at the point of access healthcare system, and it’s a battle that’s over. We lost.

This time last year I was on the street, on my own, staging a one man protest against a government dismantling the NHS and getting away with it. On my birthday a month later I organised a group protest, a Crash Call for the NHS, to raise awareness. Since then we’ve been on the streets, on your televisions, in your newspapers. The NHS is going under, we said, it isn’t safe, we said, people are dying. 

But the government spin machine is immense, and effective, and perceptions have barely changed. 

I was going to write a blog about this suspicious article in the BBC, claiming consultants are overpaid, right as consultants went back to contract negotiations of their own. I was going to point out the average overtime payment is just each consultant doing 6 hours a week more, compared with their basic salary. I was going to point out aberrant arrangements like the one in the article were locally agreed, to save struggling hospitals from huge government fines for waiting lists, despite their underfunding and understaffing. I was going to point out that huge numbers of consultant posts are unfilled, nearly 40% in medicine alone, and that unspent salary cost far outweighs the cost of any ‘overtime’ consultants earn for covering those same gaps. I was going to point out yet again how the government is spinning and dog-whistling and smearing while the NHS goes under.
But I’m not going to. I tried to write a blog full of facts and hope and fight, but I find facts are useless, my hope is gone, and the fight has left.
I wrote before how exhausted we are of all of this, but it’s only got worse and it’s about to get catastrophic

If you read this and think “well the NHS is a lazy, inefficient and rubbish health system, that should be replaced”, then good for you- it’s exactly what will happen. Just check you can afford the co-payments, or insurance premiums, or whatever comes next.
If you read this and think “this can’t happen, but what can I do?” Then think harder. 

Because whatever you do next will have to come from you. This doesn’t have to happen, but sitting at home doing nothing will definitely let it. 

If you want an NHS, save it yourself. 

My name is Dr Dominic Pimenta, GMC 7304248. 

And I quit.


Labour, left, right or other, could learn something from the junior doctors 

We’ve had some rough times in our profession. Sometimes it feels like we work in a building that’s being demolished, and Hunt and friends are wearing ear-protectors and smiling, oblivious to our screams.
The frustration seeps in, and bubbles up between us if we let it-but the one thing that got the junior doctors dispute going, kept it going and pushes it still, is unity.

98% of doctors voted for industrial action. We had a forum of 68,000 doctors able to each have a voice. These are amazing levels of cohesion. The yes/no vote on the contract became bitter- that screaming frustration came through the cracks as we pulled in opposite directions. 

Which is of course exactly what our true adversary, Jeremy Hunt and co, wanted.

I felt a surge of hope again this week. The emergency campaign to raise funds for justiceforhealth against imposition hit £120,000 in just 48 hours. We remain united. We fight on.

I want to apply this model to Labour.

Full disclosure- I’ve voted all over for many years: Lib Dem, then Labour, then Corbyn. 

Now no one will disagree Labour is in a mess. Neither will any Labour supporter disagree the Tories are rampaging across the country and tearing up the welfare state. My red line issue is the NHS and the Tories are well on the way to forcing total collapse.

The back and forth between Corbynistas and Blairites/Eagle-Eyes/Smithies has been childish, moronic, insulting and divisive. On both sides. 

I think no one can disagree Corbyn has failed as a leader. His PR is rubbish- yes you can blame the media, which has been more biased against him than any political figure in recent years, but that just means he needed to work harder. Dropping press releases at the wrong time, allowing damaging behaviours by supporters to become dominant narratives, easy gaff after easy gaff for tabloids to run.

Contrast that with Boris Johnson’s PR team that plastered over exit signs at his Brexit resignation speech JUST SO THERE WASN’T A PHOTO OF BORIS AND AN EXIT SIGN. That’s PR we need in spades. 

But you also cannot argue that the wider Labour Party has also failed. Failed to capitalise on the huge influx of support and interest in Labour with Corbyn. Failed to create a cohesive opposition in followership- every labour MP voting against the leader made more headlines than the vote itself. The image of a fractured useless opposition is going to lose more votes than Corbyn ever would. 

But whatever your opinion the lesson I want to impart to you, Labour, left, middle or other, is one of unity. Watch the television interviews of junior doctors arguing over strikes, or the debate on channel 4 after the yes/no contract vote. I give you examples of how a group can fundamentally disagree and still work to a common purpose. We still treated each other with respect and civility.

In Labour, we can still agree that the Tories will ruin this country and destroy the NHS. We can still agree that whoever the leader the opposition needs as tight a team as the government.

If Corbyn stays, will the anti-Corbyn crowd stay and work with him? Unity is the only way we will win, returning to the backbenches to continue sniping will only serve the Tories.

If Smith wins, will Corbynistas stay on, and support the party that just destroyed their dream? Yes, you must. Because ultimately the party should be bigger than all of us, and if you want to change it you have to stay.

Please remember we are literally squabbling over deck chairs on the Titanic, while iceberg Tory rips the country asunder.

Working together brought out the best in us as doctors. In Labour we have to do the same. Or we will lose everything.

Time to put  your money where your mouth is, or perhaps your heart. 

It’s been two weeks since the junior doctor body voted no to the proposed contract. The contract designed to “create a seven day NHS”, which we apparently need to address “weekend mortality”. Except none of this is true. And after a year of beating our collective heads against the all, the message is getting through.
In a Parliamentary hearing in February NHS head Charlie Massey admitted he had no clue what a ‘seven day NHS’ meant or was, and no plan to create it. He was told he was ‘flying blind’ on the issue.

This week the same hearing sat Mr Hunt down, and found what we have all known all along; Mr Hunt broke his pledge to fund the NHS and lied about it. How can there be funding for an expanded service when there isn’t funding for the normal service? When the normal service is collapsing.

And while Jeremy and the managers of he NHS haven’t bothered to study a plan they claim was important enough to force junior doctors to strike over, somebody else has. Professor Bion researched the weekend ‘effect’ and staffing and said  ‘I’m convinced seven day services cannot be achieved within current funding”.

But this isn’t news. We’ve been saying it for a year. These are the sticks Jeremy and the department of health have used to beat a whole generation of professionals- the ‘spine’ of the NHS. These are the excuses they have made to replace existing safeguards on working time with flimsy untested alternatives, to discriminate actively against women and parents in medicine, to push morale in the NHS to an all time low.

So what would a rational response be? Your contract has been rejected by the majority, your reasons for creating and pushing the contract have fallen apart, you have a new fresh start in government. You would start over right? Rebuild good will?

Sadly no. Jeremy Hunt is forcing the contract through, and not only that he is now trying to blackmail the group opposing imposition in the courts, Justice 4 Health, by demanding at the last minute £150,000 in costs.

Without this money the court case will never be heard- Jeremy will be free to impose, although he knows this is illegal, and sets a dangerous precedent for every other NHS staff group behind us.

I’m tired, just like you. I just want this to end, just like you. But I also refuse to let our profession and NHS be destroyed. This is our watch. This is our responsibility.

Some of you are doctors, some of you voted No – this is why you voted No. You want a renegotiation, or a moratorium, then imposition must be stopped. It’s time to put your money where your mouth is.

Donate here.

Some doctors voted Yes- you might still want this contract. You might think it’s the best we’re going to get. The yes/no divide was bitter, acrimonious, and brought out the worst in us. A year long dispute as a united profession brought out the best of us. Whether you believe the contract is acceptable or not, we must all agree imposition is wrong. Put your money where your heart is, come together again, and support this cause.

Donate here.

If we don’t fight together, we will fail before we even begin.

The NHS is Collapsing. Part 3: The collapse is a choice, not a necessity

It’s my job as a doctor to interpret trends and analyse hodgepodge information to predict an outcome. I look at the NHS and see a single direction of travel: collapse without rapid and drastic intervention.
In a series of posts we will look at exactly why and how this is happening. This is what I see- you can decide yourself what you see.

In the part 1 here, we looked at why the NHS budget must rise 3-4% per year just to stand still.

In part 2 here we saw exactly how this isn’t happening and the catastrophic effect it’s having on the National Health Service.

Now we examine why.

It’s clear the trend of rising demand and falling budget is not compatible with a sustainable health service, and after six years, the NHS is about to collapse. The question we have to ask is why would our leaders stand by and ignore, even exacerbate, the demise of the one of the safest, most efficient and equitable healthcare systems in the world?

Medicine is all about making choices: when you are faced with two courses of action, how do you decide which to take? What do I think the diagnosis is? What is the probability it is? What is the benefit of treatment? What is the risk if I don’t treat? What is the risk if I do? Standing by and allowing the collapse of the NHS is a choice, not a necessity.

The popular myth about the NHS, and the words certain elements are already chiselling into it’s tombstone, is that it is ‘inefficient’, ‘bloated’, ‘out-dated’, and we simply ‘cannot afford it anymore’.

The entirety of that belief is simply untrue. The NHS is ranked as one of the industrial world’s most efficient healthcare systems, and amongst the sleekest in terms of money spent/individual. Far from ‘out-dated’, NHS researchers and hospitals have pioneered some of the world’s greatest medical advances;  Tuberculosis treatments and the first successful kidney transplant*, we invented surgical robots and participated in the world’s first lab grown organ transplant. Most recently we are the first country in the world to vaccinate against Meningitis B.

So the real question is “Can we afford it?”. The short answer is Yes.

The long answer is more complex. Every pound spent on a public system is a choice; it is an ideological choice, a financial choice and a political choice. When the NHS was first created in 1948, the political and financial situation was dire: the UK debt was twice the size of the economy (214% GDP), and politically Nye Bevan faced extreme opposition, including, shamefully, from the professional body of doctors at the time. Here a difficult financial and political choice was trumped by an ideological one; the idea healthcare provision should be available to all. Flash forward to 2008 and the global economic crash required another financial choice; to bail out the banks – at a total potential cost to the UK economy at the time of £1.162 trillion, which meant UK debt doubled from 39% of the economy in 2008 to 84% in 2016. 

So the choice to fund the NHS today is actually three choices: political, financial and ideological.

Financially, if we compare 2016 to 1948 – our countries debt is a third of what it was when the NHS was created. Our international counterparts in similar financial circumstances have made a financial choice to spend more of their economy on healthcare. By 2020, that gap will be much more, and we will be spending amongst the lowest in Europe. And remember spending on healthcare isn’t an economic black hole – in areas such as public health every £1 spent to prevent disease saves as much as £5 on future health costs. More on this below.

Politically the NHS remains very well supported. It was even a part of the Olympic opening ceremony. However, the last government made a political choice to stake their reputation as leaders on reducing government spending, for no good financial or economic reason. Many economists and the IMF reject austerity as a means to increase growth in a country.

So what’s the issue?

It’s ideology. George Osbourne and Cameron believed in a small state, and that private competition is the most efficient means to achieve the best allocation of resources, a principle of economics that has no evidence base in healthcare. Despite politically promising no ‘top-down’ reorganisation of the NHS, in 2012 the largest ‘top-down’ reorganisation in the history of the NHS was pushed through in the guise of the Health and Social Care Act. This made it much, much easier for private companies to take publicly funded contracts away from public hospitals. Privatisation of services increased 500% last year.

As public services decline due to lack of public funding, further private companies will come in, and without intervention will eventually take over the entire service. Re-nationalising our hospitals and GP surgeries once this happens will be nigh impossible.

So what can be done?

Well the choice to maintain a publicly funded NHS isn’t as simple as “are we willing to keep spending more money on the NHS?”

There are many areas in the NHS where vast amounts of money could be saved and redistributed, without an extra pound from the Treasury. I’ve written about this before.

The two predominant areas of waste in the NHS are not how care is given, but where care is given. Currently private finance initiative deals provide £11 billion pounds of worth to the NHS, in the form of buildings and maintenance, but will end up costing the taxpayer £80 billion in interest. Hospitals like Barts Health in London pay £2.7 million a WEEK in interest on these deals. Why hasn’t this been addressed? Again it’s a choice not to. An alternative choice would be to nationalise this debt and renegotiate it – even restructuring it to paying 1/3 less would save the NHS £23 billion – enough to fund it fully for the next ten years.

Similarly the cost of administrating competing private companies and contracts in the NHS has a huge cost – estimated at around £5 billion/year. Reverting back to a purely state-funded and public model isn’t an ideological dream of left-wing liberals – it’s a sound money saving effort. Again, it’s a choice not to do this, because ideologically the government has chosen to create a system that prefers private competition, without any good financial, economic or scientific reason.

And if we don’t plan in the long-term to prevent diseases; diabetes, obesity, falls in the elderly, stroke and heart attacks – we are shooting ourselves in the collective foot. But a political choice was made to save short-term money on public health. Cutting social care costs us 2-3x much as it saves: I regularly have patients waiting for relatively cheap social care in highly expensive hospital beds, or contracting easily preventable conditions in inadequate social situations that develop into hugely expensive and life-threatening disease.

This is what happens when an unstoppable force meets an immovable object. Demand for healthcare is currently unstoppable; it rises 3-4%/yr, and without taking preventative measures, will continue to do so. The government is apparently immovable; they steadfastly refuse to meet this demand, which every year creates larger and larger problems as patients suffer in underfunded and understaffed hospitals. Between the two the strain on the NHS has reached critical mass – it will collapse without drastic intervention.

Neither of these forces are truly immutable; we can curb health inflation with proper prevention and better social care, and we can both fund the NHS to an equivalent level for a modern industrialised country, and save vast amounts of money through removing deals that are criminally expensive and wasteful.

I hope you now see the NHS is collapsing, and in dire need of help. This doesn’t have to happen. It is a choice.

What will you choose?


Read the other parts in this series: The NHS is Collapsing.

Part 1: A Life in a Day of the NHS

Part 2: If the NHS were a patient, I’d be pulling the emergency alarm

Part 3: The collapse is a choice, not a necessity.

The NHS is collapsing. Part 2: if the NHS were a patient, I’d be pulling the emergency alarm

It’s my job as a doctor to interpret trends and analyse hodgepodge information to predict an outcome. I look at the NHS and see a single direction of travel: collapse without rapid and drastic intervention.
In a series of posts we will look at exactly why and how this is happening. This is what I see- you can decide yourself what you see.

In the first post here, we looked at why the NHS budget must rise 3-4% per year just to stand still.

In this post we will see exactly how this isn’t happening and what effect it’s having.

Imagine the NHS is a person- and it is very sick.

When I first see a patient we are trained to go about their assessment systematically. We first check their airway is clear of obstruction and they can breathe.

What do health systems breathe? Money. Everything has a cost, even in a free at the point of service system like the NHS.

So let’s look at our patient’s charts- as demand has risen the NHS has suffocated without proper oxygen to feed it.

Already an alarm is flashing; hospitals went from £0.6 billion surplus in 2010, to the worst deficit in NHS history- £2.3 billion in the red. 

If I saw this nosedive in the hospital I would pull the emergency buzzer. We have second and third opinions here too- The Kings Fund called this

the most austere decade in NHS history.

Professor Don Berwick, patient safety tsar, said

 “I know no nation that is seeking to provide [modern] healthcare at … 8% of GDP let alone 7% or 6.7%, that may be impossible “

The government spun this crisis as hospital ‘overspending‘- but that’s the equivalent of telling a gasping patient that they are ‘overbreathing’. It’s estimated the NHS needs £30 billion to keep afloat by 2020- the ‘extra’ £10 billion promised by government hasn’t appeared, is actually just £4.5 billion and is nowhere near enough. A deflated armband for a drowning man.

Next we look at the circulation, which is how the blood flows through the body and delivers life to the vital organs. What is the lifeblood of the NHS? The staff.

And we are haemorrhaging out. Just like our real blood the NHS system is made up of lots of essential components; doctors, junior and consultant and GP, nurses, midwives, paramedics, pharmacists, health visitors, radiographers, physio and occupational therapists, clerical and secretarial staff, cleaners, security. The list goes on. Every single staff group is suffering.

In the last two years the number of vacant posts for doctors has increased 60%, the number of gaps in nurse’s posts 50%. GPs are contemplating mass resignation, community pharmacies face mass closure, and the cuts to student nursing bursaries mean fewer nurses will be enticed into training. And junior doctors? Alongside most NHS staff junior doctors have already taken a 25% paycut in real terms since 2008, and certificates to leave the country are on the rise.

Now thanks to a toxic contract dispute they are leaving training in England; first choice applications to Scotland and Wales jumped 30-40% vs 2015, and first year training was under recruited in England for the first time in history.

The NHS needs a rapid and skilled workforce transfusion, and to stop bleeding staff burnt out by demoralising leaders and working environments.

The next step in a real patient is to assess their brain- so who are the brains? Well, Jeremy Hunt is still Secretary of State for Health, a man who looked at the above gasping and bleeding patient and declared “the NHS needs to go on a ten-year diet“. I think we need a brain transplant.

Then we assess the vital organs. What are the vital organs of the NHS? A&E, GP and cancer care. Let’s look at some test results. A&E is crashing- wait times over 4 hours just hit the highest in history, with just 81% of patients seen in target time compared to 98% just 8 years ago.

A&Es are closing and downgrading due to lack of staff and funding and no plan to cope with demand when other local departments close.

GPs are closing at record rates– and some being sold privately for more money, and for the last two years we are consistently missing cancer targets.

And let’s not forget the huge problems in social care funding. Even if we resuscitate our dying patient, we can’t forget that their house is caving in as well.
In the midst of all of this the government want to launch a ‘seven day service’, and deny there are any problems at all. Some NHS leads are even starting to leave reality altogether and claim ‘we don’t need safe staffing levels’.
Imagine a crowd of very concerned doctors and nurses around a very sick patient, tubes and wires and monitors blaring, and in jumps Mr Hunt, trying to shoo attention away and declaring “He’s just overbreathing and needs a good diet is all!”. As a doctor I would be within my rights to have him thrown out of the hospital. I can’t seem to get him thrown out of government though.

And as our leaders withhold the vital oxygen our patient NHS needs, as they fail to address the profuse haemorrhaging and the multi-organ failure, we have to ask why? Why would a responsible government be so wilfully ignorant of such catastrophe? And can we hope to resuscitate?
Find out in our final instalment;

The NHS is Collapsing Part 3: The collapse is a choice, not a necessity. 


Read the other parts in this series: The NHS is Collapsing.

Part 1: A Life in a Day of the NHS

Part 2: If the NHS were a patient, I’d be pulling the emergency alarm

Part 3: The collapse is a choice, not a necessity.

The NHS is collapsing. Part 1: A Life in a Day of the NHS 

So May is in, Hunt stays, Brexit means Brexit. It’s all change in a crazy week of politics. But what hasn’t changed is the NHS is still about to collapse. May will likely be the last Prime Minister to oversee its demise.

It’s my job as a doctor to interpret trends and analyse hodgepodge information to predict an outcome. I look at the NHS and see a single direction of travel: collapse without rapid and drastic intervention.
In a series of posts we will look at exactly why and how this is happening. This is what I see- you can decide yourself what you see.

In this part we will simply explain why the cost of modern healthcare rises every year just to stand still, which is fundamental to understanding the funding needs of the NHS.
This is difficult, but I think best explained if you simplify the entire health system as treating a single person, let’s call her Beverley.

Beverley is born in 1948- her birth is at home, with no healthcare professional, midwife or monitoring. Several of Beverley’s siblings are also born this way- unfortunately two die before they are one. Sadly an uncle has a heart attack at 52 and passes away.

Beverley grows up, and fortunately remains healthy. She marries, Bob, and she has her kids in 1968. She has every one in a hospital, with a midwife. One requires surgery. Beverley’s own mother has a stroke and dies at 63. Bob decides to stop smoking.

Beverley gets older. Her first grandchild is born in 1988, in hospital with electronic monitoring and emergency caesarean. Beverley’s second grandchild is born at 25 weeks, and spends three months in the new intensive care baby unit. Stressed grandparent Bob has a heart attack- he is rushed into hospital and has an emergency procedure to open the blood vessels in his heart. He is at home in time to hold his new granddaughter for the first time.

Beverley and Bob stride on, both retiring at 65. On their 50th wedding anniversary Beverley feels odd, can’t find the words to toast, and can’t raise her left arm. Her daughter dials 999- Beverley has a stroke, just like her mother. Fortunately she gets to hospital and 30 minutes later she has had a brain scan and a clot buster is being infused into her arm. She makes a full recovery, and goes back home a day later.

The junior doctor looking after Beverley spots a shadow on the routine chest X-ray she has. She is diagnosed with lung cancer.

Bob is going spare. They meet the specialist, the cancer is treatable and they start right away, six rounds of radiotherapy then weekly chemotherapy. It’s hard, and Beverley goes into hospital twice with complications.

Halfway through Bob has lots of abdominal pain and throws up some blood. Rushed to hospital he has an emergency camera test into his stomach – he’s developed a stress ulcer, which they clip and repair. He’s in hospital for a few days. Gratefully Bob and Beverley return home.

Beverley goes into remission, but is very frail now and is falling a lot at home. Now in their 80s, Bob gets chest pain trying to look after them both, and Bob needs three more stents put in to open blocked heart vessels. Bob and Beverley ask for some social services support at home- a carer comes once a day.

Overnight one night, Bob passes away in his sleep. Beverley is distraught, but at the funeral she asks her daughter; “Where’s Bob?”. Concerned, her daughter takes her to the GP. It’s clear Beverley now has dementia. She is moved first to a sheltered flat, then a residential home, then a nursing home.

She dies in hospital of a severe pneumonia at 83.

This isn’t a sad story- this is modern life and modern healthcare.
Why did i tell you this story? To show you how healthcare has changed. Let’s look at some facts.
In 1948 the average female life expectancy was 71. In 2016 it’s 81.5.

Beverley’s mum died at 63, while Beverley lived into her 80s. People are living longer.

Why? Better healthcare, better immunisations and prevention, better nutrition.

But also diseases that were previously fatal are now treatable. Mortality for conditions such as coronary artery disease have halved in fifty years- Beverley’s uncle died of a heart attack, but Bob survived two. Stroke survival and stomach bleeds are now readily survivable where fifty years ago they were not.

But these treatments are very expensive- the technology to open blood clots through vessels is super high tech and costs £3000 a go, advanced chemotherapy and radiotherapy treatment costs can run to hundreds of thousands per person, and intensive baby care costs £12,000 a week.

In short- we can do more every year, so we do. And those that we save live on as survivors- but this comes at a cost.

The cost of healthcare per year for an 85 year old is around 4x that of an under 65. The proportion of the population over 65 will rise to 25% by 2040. And alongside that the population is growing, by around 30% since the start of the NHS- so there are 30% more Beverley’s and Bobs than we started with.

So more people, who need more treatment, are treated with more medicines and survive more to need more treatment in the future. And let’s not forget they will need more social care.

This is why the NHS needs 3-4% more funding every year.

That seems like a lot- it’s a tremendous challenge. But we aren’t rising to it as our neighbours are. Of the G7 countries we currently spend the 2nd least on healthcare, well behind the US, Canada, Germany and France.

With the current healthcare budget under the Tories, we will be spending just 6.7% GDP by 2020- lower than Lithuiania and Hungary.

Despite that the NHS is still consistently ranked as one of the best healthcare systems in the world. In 2012 the US commonwealth fund found it the most efficient, safe and accessible system out of all countries ranked, and also spent nearly the least.

So now you now that the NHS needs a rising budget to meet rising demand, like every other modern country. Yet we aren’t funding it anywhere near that level, and we aren’t meeting that demand.
In short, the NHS is about to collapse.
Find out how in;

The NHS is collapsing. Part 2: if the NHS were a patient, I’d be pulling the emergency alarm.


Read the other parts in this series: The NHS is Collapsing.

Part 1: A Life in a Day of the NHS

Part 2: If the NHS were a patient, I’d be pulling the emergency alarm

Part 3: The collapse is a choice, not a necessity.

I have a simple question Mr Hunt- what is the rush?

Today Jeremy Hunt announced a return to imposition. He justified this despite an emphatic rejection of the contract by 58% of the referendum voters, to end the ‘impasse’ after three years and failing to agree a contract. 
But the one question no one has answered for me is “what is the rush?”
Now the government would argue that they are keen to get on with their ‘seven day NHS plans’, despite the fact that the NHS is about to announce even greater spending cuts, George Osbourne has abandoned his surplus target for 2020, and record number of staff gaps for doctors and nurses are being recorded. Categorically, there is no plan for a seven day NHS, vis a vis there is no seven day NHS. What did we get instead? “Junior doctors are now a third cheaper”. There aren’t any more doctors- in fact many have now fled for Australia and Scotland. So no more doctors on weekends- just a third cheaper.
And whatever happened to the ‘weekend effect’- suddenly missing from what was core Hunt go-to doctrine? Well new evidence has dispelled this effect, making it more an artefact of how dodgy data was collected, and subsequently misrepresented. We’ve covered this before. Put simply- there’s no weekend effect for this contract to address.
And even if there were, junior doctors already work 7 days a week, no study ever linked junior doctor staffing to any ‘effect’ and the one study Jeremy likes to quote actually found 100% medical coverage across every day of the week. So this contract fight arose from a political position that has since crumbled away.
So what’s the rush? What’s the benefit of imposing a contract, which is legally fraught, onto a highly mobile professional body, highly
Motivated already to leave? 

Now the government might turn back and say- well it’s been three years, and we still haven’t got anywhere.
Be that as it may- but why can’t it be three more years? If this was genuinely all about making patients safer, which it certainly doesn’t now, then why not take the time to actually achieve that?
Let me tell you about the contract. It is going to cover every NHS England hospital- so every patient in England will be affected. 
The central Guardian role for protecting doctors from exhaustion, a key concern about this contract, has been rushed through in weeks- but practically no planning has been done. 

Some hospitals have recruited this role for a mere 4 hours per week, looking after 1200 doctors. That’s just 12 seconds a week per trainee. Is that sensible or practical?

There is no plan for how human resource departments will be able to cope with the sudden ten-fold increase in complexity in the pay and rostering schedules, nor any plan for how educational supervisors, busy doctors in their own right, are now expected to take on a huge additional workload, another key part of safety completely mismanaged.

We don’t have an effective means of whistleblowing without getting sacked. Put simply- if I find a horrendous breach of patient safety neglected by my hospital management, and blow the whistle to protect patients, I can be sacked from my training post with impunity. Is that a good thing?

Lastly negotiations were still in progress to address the key discriminatory parts of the contract. As it stands it still will mean the careers of female medics are more difficult Than they are now. We are bleeding staff and resources in the NHS- what is the possible benefit of rushing a contract through that will lead to fewer doctors on shift, not more? Is that good for patients or staff or anyone at all?
You might argue that the BMA agreed this contract, and therefore it’s okay to impose it. Which is a rather paradoxical argument from just a few months ago when we were told the BMA were misleading us, now we should blindly follow?
 Certain social media commentators ardently claim we are naive and childish. We are a group of people with an average of two university degrees each, twenty plus years of education, an average age of around 33, and many of us mothers and fathers ourselves. 

We understand perfectly.
We understand the rush is a political expediency- politically this needs to be out of the news cycle, politically it needs to be off the front page, politically this needs to be out of the next election cycle. But I’m sorry, we aren’t creatures of politics.
We are doctors responsible for human lives; and we see a contract that will push more of our colleagues away from the bedside, stretch the doctors that remain, and leave no means to correct continued unsafe working. I’m not exaggerating when I say this contract imposition may hasten the end of the NHS, and has the very real potential to kill people. It’s not a decision we take lightly or naively. It’s also not a decision or negotiation to rush. 

So Mr Hunt, I ask you again: what is the rush?
Work with us for a year to improve the safety mechanisms we have, to retain less than full time staff, to restore the morale and hope of us all. You keep telling us we are the ‘backbone of the NHS’. You are about to break it.
You don’t need a doctor to tell you that’s a rather fatal idea. 

The junior doctor contract? It’s a No.

I flip flopped on my position on the contract vote, and I make no apology for it. It was a difficult decision, in a completely crazy political and NHS environment, and I never spoke to anyone who had a completely clear idea on it. 
68% of doctors voted, and 58% voted no. Given the margin we just left Europe on, this is pretty emphatic. 
So what happens next?
As he always said he would, Johann Malawana, current junior doctor committee chief has stepped down. I always supported Johann, and he has been an incredible leader in unprecedentedly difficult times. I wish he’d stayed on to be honest, but respect his decision and we should be eternally thankful for his service. 
As I’d suggested before, we now need to decide what we want, what we are willing to do to get it, and how we want to go about it.
The strategies now open to us depend on what government’s response will be.
If renegotiation is offered;
1. complete restart on negotiations. With a civil service in Brexit disarray, and no actual leadership in government right now, this may be more viable, or less, than it was a week ago. We simply don’t know. Whatever the circumstances a new contract must have; 
              -Safe staffing and working conditions 

              -no discrimination 

              -fair remuneration

              -whistleblowing protection

2. Further negotiation on the current contract. This might be difficult- there were many reasons and red lines for different doctors- simply tacking on and rejigging this contract might still fail to convince the junior doctor body that already voted this offer down.
3. Or do we push for individual negotiations for different specialties and colleges? A more tailored approach that might address the one-size fits all difficultly of such a complex contract.

4. Or do we simply campaign for no more negotiations- a moratorium on any further discussions for at least a year. Let the politics cool down, let politicians leave the issue alone and the newspapers to wander away. Then, when safe to, we can pick it up again- with time for a better plan regarding an option above. 

The government may impose. 
If they do – then what?
42% of doctors accepted this contract- if you voted yes are you willing to now take part in industrial action with those who voted No?

I might suggest that doing anything other than staying united in support would be foolish. If the government impose, they are more than likely going to change the contract as they did in the original imposed version. Clauses such as ‘we can change anything at any time’ and ‘you can only work for us’ might reappear. Any supplements and premia may disappear, the safety mechanism may also disappear. The contract we may end up striking against may be very different to what we have now.
And if it isn’t? Will it attract the same support for industrial action as before? 
Well we will have to see. Imposition may be illegal, regardless of the terms, and Justice for Health and The BMA both have legal challenges to play out in the courts. 
At the end of the day we all simply want our lives back, we don’t want a payrise, we don’t want special conditions or further perks; we are simply asking that government leaves us alone, and let’s us go back to the jobs we love; looking after patients.
So let’s just put this toxic issue to one side, continue current contracts everywhere, and spend the time restoring goodwill and trust so we can safeguard patients and doctors for the future of the NHS.
Whatever happens we must stay united.

The world is crazy enough right now. Lets hope a bit of sanity can prevail.