Dear (brand new) Doctor…

To all the new doctors,
First and foremost, I think I speak for our profession, junior and senior, when I say, Welcome.
Tomorrow will be your first day as a doctor. A day you have probably thought about for a decade or more, but perhaps could never quite imagine. 

From Hippocrates to Osler, Galen to Gawande, every medic of every age had a “first day”. Be careful with the advice you listen to, there are as many ways to be a doctor as there are doctors. This is my advice, please feel free to take it or leave it.
1.Looking after humans is a messy business, literally and figuratively. Know where the scrubs are kept. Don’t wear shoes you can’t afford to throw away.

2. There’s always time for lunch. Your stomach won’t thank you for ignoring it, but worse, your patients won’t either. Irritable doctors make crappy decisions. 

3. Look after your back. Sit down to cannulate or bring the bed up so you don’t have to. Your fifty year old self will thank you.

4. Be nice to your fellow F1s. They will be the closest colleagues and friends you will make in your career. You will go to their weddings and hold their newborn babies. Like soldiers on the battlefield you will be bonded for life. 

 5. Be nice to everyone else too- even when others don’t reciprocate. You never know when you’ll need their help. Successful medicine is sometimes about who you know as much as what you know. Learn to know when you should bite your tongue.

 6. And when not to. Ultimately the patient is your only priority. If you need to voice a concern, do so, loudly, coherently and without anger, to whoever, however high up, that you need to. 

 7. Don’t drink too much, if you do. It’s easy to let one glass become two, become three. Don’t drink your stress, find better ways to deal with it. 

 8. Learning from your own mistakes is mandatory. The price of a mistake is high, you must do everything you can to recoup that cost. Better still, learn everything you can about other doctor’s mistakes, so you don’t repeat them.

 9. Find what you’re scared of, and run towards it. I was terrified of cardiac arrests so I used to run to every single one. Now I’m a cardiology registrar. Life is funny like that.

10. If you’re not sure about a drug dose, look it up.

11. Look up anything else too. Google diagnoses when you’re not sure. Don’t be dismayed, your seniors do this all the time, probably more than you. Knowing what you’re talking about is much more important than merely looking like you do.

12. Find a toilet that no one else uses. Trust me on this.

13. Take all your leave. Go on holiday. 

14. Recognise you made a choice to be a doctor, take pride in and be empowered by that choice.

15. But also recognise when you see a patient they didn’t get a choice, and they didn’t choose you as their doctor. You have a responsibility to be the best doctor you can be in that moment, because that patient doesn’t get to choose anyone else.

16. Keep your moving boxes- you’ll need them again.

17. Understand you work at a nexus point in a patient’s life. Patients come in going one way in life, but oft-times leave going somewhere completely different. Sometimes, sadly, nowhere at all. That enormity of exposure to Life can take it’s toll.

18. Talk about it. Cry about it. Commiserate with your colleagues, support and celebrate with them too. Deal with your emotions fully, or they will overwhelm you.

19. Try your best, always.

Feel free to heed or ignore any of the above. Add your own pearls as you find them.
Tomorrow is your first day, doctors, and truly the first day of the rest of your life.

It is genuinely the most wonderful job.

Good luck. You will be brilliant.
Juniordoctorblog.com

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“Your Life In My Hands” by Rachel Clarke. A juniordoctorblog.com review

“The unexamined life is not worth living”
Socrates

 

There’s an inextricable link between medicine and books. To a medical student books are both stepping stones and obstacles, huge tomes to surmount as much to absorb. Later, they become totems, a copy of the ubiquitous Oxford Handbook of Medicine, colloquially known as the “Cheese and Onion”, jammed into a scrub back pocket to ward off disaster and protect us from our own insecurities and our patients from our inexperience. Later still, books become mirrors, reflections that let us examine our own careers and lives.

Reading the rather wonderful “Your Life In My Hands” by Dr Rachel Clarke leads to it’s own examination. Dr Clarke writes with a prose that is both immediate and personable, dumping you straight behind the eyes of an NHS junior doctor, bursting bladders, blood-soaked scrubs, desperate tears and all. This book is a portal into our hospitals, coming at a time when it’s never been more important to be able to share the actual reality of the NHS frontline.

Full disclosure: I’ve met Rachel Clarke. We swam in similar circles during the junior doctor contract dispute. When she and Dr Dagan Lonsdale kicked off the 24-hour protest TimeToTalkJeremy, outside the Department of Health, I was working just up the road and went down to show solidarity. Unflappable, sincere, ever-smiling; she was hugely inspiring and extremely nice. A few days later I was sitting in the same chair.

Before this book landed on my doormat, I knew Dr Clarke was a great writer and a shining example of our profession. It was the parts that I didn’t know that made this book so surprisingly brilliant. Besides doctoring, her semi auto-biography takes the reader through her past life as a TV journalist, dodging bullets in the Congo, filming experimental deep-freeze neurosurgery in the US, casually bantering with Alastair Campbell and Prime Ministers. Weaved throughout this rich tapestry of past and present, Dr Clarke paints the powerful and undeniable picture of an NHS being failed through short-sighted politicking and chronic underfunding.

For me, reading this book forced me to re-examine my own career. Her descriptions are achingly accurate: of the crash-calls, the dark quiet moments with a dying patient’s family, the highs of a shot-in-the-dark diagnosis or a surprise success where it seemed impossible and the lows of the true tragedies, dealing with the pieces left behind. I have been there in every one. We all have. And now you have too.

And that is the true beauty of “Your Life In My Hands” – it brings to life with dazzling perspicuity, not a unique experience, but a ubiquitous one. This is a junior doctor’s life, as damn near as you can get without living it yourself. And even if you have, it’s worth reading for the mirror it holds back. I left medicine after the burnout of the junior doctors contract dispute, and then, like Dr Clarke, rediscovered my love for it again. Reading this book made me remember exactly why.

The NHS is consistently the number two top issue of concern in UK opinion polls. A “political football” to some, often those campaigning for it are accused of “weaponizing” the subject. The true power behind this book is Dr Clarke’s ability to humanise it. The irony of “Your Life In My Hands” is in it’s title, because once you’ve bought this book, you are holding a life in your hands. Once you’ve read it and experienced it, you will see the NHS one hopes, as we see it. And then, as Dr Clarke masterfully surmises, you will realise that the future of the NHS is not in our hands, but yours.

juniordoctorblog.com

Your Life In My Hands by Rachel Clarke is out now.

 

Austerity in essential public services is deadly. Grenfell demonstrates it. The NHS exemplifies it.

“I seem, then, in just this little thing to be wiser than this man at any rate, that what I do not know I do not think I know either..”
Socrates 

Apology by Plato

The events of the last week will undoubtedly shape the future of Britain in a monumental fashion. First, an election like none we have seen for fifty years. Called in hubris, led to nemesis, won, in truth, by no one. History-making nonetheless. The prevailing wind of politics has changed, now blowing Left of centre for the first time in nearly a decade. Corbyn has an approval rating of +6, Theresa May a disapproval rating of -34, nearly mirror opposites of where they stood in November. Who knew?

Theresa May and the Conservatives struck a conciliatory tone. “Austerity is over” they said, in radio interviews, in leaked excerpts from backbencher committee meetings. The “mood has changed” they said.

And then Grenfell Tower happened. And the mood changed again.

As details drip out of what will undoubtedly be known as the biggest domestic disaster since Hillsborough, a hazy but consistent picture coalesces. The fire began reportedly in a fourth floor flat, starting with a fridge. The residents had campaigned for years before about power surges in the building, about the risk of a lethal fire with appliances, but sadly, were ignored. Within minutes, it is reported, the fire had spread out of a window and roared up the side of the tower, consuming the external cladding system as one resident described “like matchsticks”. This external cladding had been part of a recent £8.7 million refurbishment, subcontracted by the private enterprise managing the tower, KCTMO, to update the insulation and aesthetic aspects of the outer structure. In the Times today, it is reported that the cladding material used is illegal in structures greater than 18 metres, is flammable when an alternative fire resistant material would’ve cost just £5000 more, and is illegal in Germany and the USA. Sky News’ Faisal Islam shared a BRE presentation this weekend, a diagram of exactly the kind of disaster that befell Grenfell, dated June 2014, three years ago exactly. In summary, we await the public inquiry that must happen, but it seems 58 (at time of writing) people died in a preventable disaster, that was forewarned, already forestalled in other countries, and seems to have been the result of thoughtless (one hopes) cost cutting from a private company.
But, as Damian Green stated in an extraordinary Radio 4 interview, “we must await the experts”.

Which struck a chord with me.

The mantra “prevention is better than cure” is as true in medicine as it is in fire fighting. Much of what we do, day to day, is about preventing future disease, rather than treating it’s corollaries. We use safety cannulas for preventing needlestick injury, we campaign to stop smoking to prevent lung and other cancers, we screen and treat alcoholics on admission to hospital to prevent deadly withdrawal seizures. When we see impending disaster threatening human life, we have a duty to act, as best we can.

A disaster likely already happened in the NHS, and I cannot help but see the parallels with Grenfell. In February of this year a Royal Society of Medicine Report looked into what was explained away by the government as a “statistical blip.”. Since 2010 the death rate in the U.K. was rising, for the first time in fifty years. More people were dying. To be exact, 30,000 “extra” people died in 2015 compared to what was expected. This study attempted to explain where these extra deaths came from. Was it a subpar flu vaccine one season , as Jeremy Hunt, once and current Health secretary, had claimed? No, the study concluded, the only explanation that fit the data was that 30,000 excess deaths were most likely a direct result of cuts to health and social care services.

Let that sink in.

30,000 men and women, potentially your grandmother or father, sister or uncle, whose deaths were in some way contributed to by cuts to services in the name of “austerity”. Like Grenfell, cutting corners and saving pennies, led to a national disaster. Like Grenfell, multiple agencies have limited oversight over the system as a whole. Yes, the buck stops with the government, but I’m sure they can pass it through any number of government and non-government subsidiaries. Like Grenfell, this essential public service, is sub-contracted in places to private companies, beholden to shareholders as much, if not more, than to the public they are supposed to serve. And like Grenfell, warnings about impending disaster, from “experts” and public alike, have fallen on deaf ears. But unlike Grenfell no one saw these deaths for what they were, a national disaster on a behemoth scale.

Austerity kills. It has already potentially killed 30,000 men and women in health and social care. It has killed at least 58 in Grenfell last week. It has killed thousands of disabled people whose benefits were removed just months before they died. Who knows where else this cost-cutting at any cost has cost lives to save pennies?

If you think I’m politicising this tragedy, you have it backwards. The politics came first, then the tragedy.

Which brings me back to where we started. “Austerity is over” they said. The “mood has changed” they said. As if austerity were always a fanciful choice, a frivolity that was chosen on a whim, as one might decide on a suitable tie, or a wallpaper for the living room. I don’t remember anyone claiming austerity was a “mood” when Osbourne and Cameron were laying waste to health and social care budgets, schools and police funding. Austerity was essential, they said. We have to “live within our means” they said. Except some of us didn’t manage to. Potentially as many as 30,000 of us, our most vulnerable.

So now austerity is over. Was it ever actually necessary? The short answer is no. The long answer is, perhaps for a while, but ultimately still no. Despite what the Mail and Sun has peddled for half a decade, the idea the economy is akin to a household budget is laughable. Pretending we only have control of spending in a government trying to “balance the books” is patently stupid; a government sets it’s own revenues, through tax and VAT, NI and council tax, levies and custom duties, subsidies from other countries, like the EU. Austerity was harmful to our economic recovery. This isn’t left wing socialist claptrap, this is mainstream economics. The IMF agrees as did a large backing of the UK’s top economists. This is economic theory that goes back a hundred years. Any economist could’ve told you that. But of course, we had had enough of listening to “experts” then.

Apparently that’s all changed now.

If we are listening to architects and fire officers again, perhaps we could list to economists and health experts again too, to teachers and police federations. To paraphrase Socrates, wisdom is knowing what one does not know. As a doctor I’ve begun to understand this more and more. Being conscious of the limits of my knowledge makes me safer, means I can operate with uncertainty and know where I need a colleague’s advice, or my boss.

In the age of the internet it seems we now know everything, but understand nothing. For too long we all “knew” that austerity was necessary, that “too much red tape” was throttling business and enterprise, that the NHS was “bloated” and spending “too much money”. Did any of us examine where this “knowledge” came from?

Now we see we knew nothing at all. I hope from these tragedies we can salvage some wisdom.

In an impassioned interview, the MP David Lammy spoke about the “safety net” of schools and hospitals, of decent housing, that is falling apart all around us. Austerity has shredded that safety net, and many have died slipping through the gaps.

Austerity is over, they say. I think we can rebuild this safety net, I hope we can fix the NHS.

But then, what do I know?

Juniordoctorblog.com

Dear Other Normal Human Beings

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

You, like me, wake up in the morning and sleep at night, eat meals, sometimes with loved ones, sometimes alone. We are alike in our requirement for other people, for happiness, for security, for food, for warmth, for shelter.

You may have children, you may have brothers or sisters. You have, or had, parents, and perhaps were lucky enough to know your grandparents.

You may have noticed that many health professionals were becoming uncharacteristically vocal, leading up to the General Election. You may have thought them self-serving, morally bankrupt individuals, upset over their own pay packets.

I would like to explain to you, from one normal human being to another, what is going on.

I am a doctor. I decided to be a doctor before I really knew what decisions were, and can never remember wanting to do anything else. Once I knew how, I found the path, and worked my arse off. Six years, in secondary school, studying. Two years, in college, studying. I took four A-levels, I had 25% less free time than my friends, and when they were out, doing whatever they wanted, I was not. I was studying. Another six years at medical school, studying, and sometimes working to pay for the studying. The last three years of medical school I worked harder than I ever had, and the same hours as a full-time professional, sometimes way more. It even made me sick- in my final year I developed acute gastrointestinal bleeding. But, becoming a doctor was all that meant anything to me. So, I took my top grades and turned them in, in return I got fourteen years hard graft, and £50,000 worth of debt. [2]

Why is this important? Because, from the very beginning, I knew about sacrifices. As thousands of my colleagues have, as millions before me have, and millions will. I knew about sacrifice when I worked for a year before university, so I could afford the rent, when I missed my first family Christmas to work as a warden in student halls, so I could afford to stay at medical school. I knew about sacrifice when I missed nearly every other Christmas since, working, or sometimes studying. I knew about sacrifice when I’ve missed my friends weddings, my nieces and nephews birthdays, when everyone I knew was travelling, and I was studying, or working. Being a doctor, and it’s inherent position in society and in the hearts of the public, is irrevocably tied to sacrifice- it’s the dedication it takes to become, and to stay, a doctor, that by definition requires sacrifices to time, to personal satisfaction. All over the country right now, doctors and nurses, physiotherapists and occupational therapists, radiographers and ward clerks and all the other medical professionals are sacrificing their lives, minute by minute, to try to give you or your loved ones minutes, hours, days or years more. So, when, as a normal person, someone tells you doctors don’t understand ‘vocation’, you know now- it is beat into us before we even get through the door.

But, as a normal person, of course you understand why doctors would defend the NHS, would fight to protect it, and so vociferously attack it’s detractors. They have a vested interest, they want to keep their cushy salaries and great jobs, and the NHS is great for that.

Let me tell you straight: if I didn’t care about you, or my patients, I would be out there campaigning to close the NHS right now. I would make more money in the private sector in a  day than I would in two weeks of NHS work. I could also take my UK Medical degree, one of the most respected qualifications anywhere in the world, and go and earn 50-200% more in the US, Australia, New Zealand [3]. In the private sector, if I stayed after 5pm to look after you, the next thing you see after my smiling face as you exit the hospital, will be the bill on the doormat; ‘overtime’, ‘time in lieu’, ‘additional hours rates’ aplenty.

But, I, like you, have a family. I went to state school, and worked and grafted to pay for my six years at University. Without the NHS my grandmother would have gone blind, my father would have had several heart attacks, my mother would have died. I might have died. A private system would’ve bankrupted them, ended their hopes for a better future in order to pay to survive. I, like you, would do anything for the ones I love, and that is why I campaign to protect and improve the NHS. And that is why, when 5pm comes and goes, as does 6pm, 7pm and all the other hours in between, I, and every colleague I have ever worked with, stays for their sick patient. Because, one day, somewhere, for someone else, that patient will be their mum, or dad, wife or husband, son or daughter.

We have had, and always have had, the extraordinary privilege of one the greatest healthcare systems, pound-for-pound, in the world. The reasons for it’s great outcomes and low cost are debatable. But there are some reasons we never mention. This country has a medical school system of international renown, whose doctors, for the most part, qualify and stay exclusively working within the NHS. The staff of the NHS gives untold free hours to the profession; when I was a first-year junior doctor, I calculated I worked one day at work for £4.10 an hour. I used to get paid more at Tescos. But a very sick patient needed a lot of complex care, and so I stayed, and helped, and he survived: as millions of patients have since 1948. [4]

The moves of the current government against the medical profession are calculated: to deride working conditions, salaries, hours and deplete hospital resources, until a normal person, like myself, buckles under the social, financial and emotional cost. At that point, a sea-change of new, private hospitals will open, and we will go and work there. And our lives will be pretty much the same- different bosses, the same bureaucracy and probably better pay. But our lives, as normal people, will not. You will still pay taxes, a stripped-down NHS will persist, for no frills, emergency care only, but not for all the other healthcare needs of a 21st century population: you will need private healthcare. And that healthcare insurance will cost you hundreds of pounds a year, if not a month. And if you don’t have insurance, you will spend thousands of pounds on the simplest, quickest procedure [5]. And the NHS won’t be there for my family, or the families of normal people across the country.

So, I want this to reach as many normal people as it can. If you don’t act now, it will be too late. It might already be too late.

We care deeply because we can see the great good the NHS does, every single day. And I care because, like you, I care about the ones I love.

Where can you start?

June the 8th, 2017

At the polling booth,

Yours sincerely,

juniordoctorblog.com

[PART 2: A Factual Appendix]

-What normal people appreciate, are hard, solid, unflinching, facts. So here they are.

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

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

UK data: http://bma.org.uk/practical-support-at-work/pay-fees-allowances/pay-scales/consultants-england
US data: http://www.payscale.com/research/US/People_with_Jobs_as_Physicians_%2F_Doctors/Salary.
Australian data: http://www.imrmedical.com/australia-salaries-tax
New Zealand data: http://www.imrmedical.com/new-zealand-salaries-tax

[4] The NHS opened it’s doors, metaphorically, July 5th 1948. It’s first patient was a 12-year old girl with a liver condition. http://www.legislation.gov.uk/ukpga/Geo6/11-12/29

[5] This is incredibly interesting reading, although it is for claims, it is still very reflective of the actual cost. https://www.freedomhealthinsurance.co.uk/downloads/your-choice-procedure-payment-guide

Is being a doctor just a job?

You hear this phrase a lot; being a doctor is “just a job”, but funnily enough in widely different contexts. On the one hand, the “higher calling” of medicine is derided by some, who insist it’s “just a job” like any other. On the other, doctors under extreme pressure need to know sometimes that their work is “a job”, it should stay compartmentalised and allow them a life outside the hospital or surgery, to balance their own mental health against their working lives. 

Which is it?
I don’t think anyone who has working in any emergency setting with human beings would accept the derogatory label of “just a job”, whether that job is doctor, nurse, physiotherapist, pharmacist, fireman, policeman, or paramedic. The normal course of a human life is long periods of normality and stability, punctuated by “Life” with a capital L; births, deaths, marriages, divorces, comedy and tragedy. There’s only so much of that a human mind can take, few of us can stand constant turmoil and upheaval. That’s why the mental health of those in extreme situations suffers: refugees, long-term domestic abuse, and homelessness amongst others. 

Being in an emergency job such as medicine means you are party to a constant stream of Life events: births, deaths, monumental illnesses. All the things that intrude into our bubble of stability to rudely remind us of what we already know but wilfully forget: life is random, and hard, and cruel, and important, and wonderful. 

So medicine isn’t “just a job” in that sense: it’s an enormous privilege to bear witness and to help human beings through the hardest and most real times in their lives. 

But if you let that tragedy in too much, you expose too much of yourself to that constant stream of suffering, you run the risk of your own mental health, exceeding your mind’s capacity to process capital L Life events.

That’s why it’s important to know in a positive sense that medicine is “just a job” too.

Knowing it’s “just a job” means you know you can walk away, which validates and empowers that unconscious choice to walk back in again. 

We all chose to do something important with our lives, but we should all recognise that that was a “choice”, and take heart in that. 

We should always recognise that we chose to help others, and that no one has an infinite individual capacity to do so; that’s why we work in teams, that’s why we do go home, that’s why we should remember to look after ourselves so we can look after others properly.

So yes, medicine is “just a job”; you have the freedom to walk away at any time, and, I hope, be empowered to choose to come back again. It’s a job, yes, but it’s a job like few others; it’s an enormous privilege and it is honestly one of the best jobs in the world.
juniordoctorblog.com

Is the NHS really over? Just the facts.

“You are entitled to your own opinions, but not to your own facts.”
Patrick Moynihan, four-time US Senator

Is the NHS failing? Research shows the introduction of factual evidence into a polarised debate actually makes the two sides less likely to agree than to agree. However, as a doctor I like cold, hard facts. In our line of work anything less is morally wrong and overtly dangerous.

So here is the NHS. Just the facts (with references). 

  1. The population of the UK is an estimated 65.1 million. 
  2. 1 in 20 GP surgeries have closed or merged since 2013. 57 closing down in 2016 alone.
  3. The NHS England budget is £117 billion for 2016/7 and will rise after inflation to £120 billion by 2019/20. 
  4. Every 36 hours the NHS will treat 1,000,000 patients. 
  5. Accident and emergency departments recorded their worst ever waiting times in 2016/7.
  6. Hospitals recorded their worst ever waiting times for elective surgery in 2015. 
  7. The NHS in England has 149,808 doctors, 314,966 nurses, and employs 1.3 million people. 
  8. 19% of NHS staff and 29.5% of NHS doctors are non-British
  9. The average age of recent migrants to the UK is 26.
  10. Healthcare costs change with age: a 20-year old costs an estimated £900 per year, a 65-year old £3750 per year and an 85-year old £7500 per year. 
  11. The population of the UK over 65 in 1975 was 1 in 8. Today it is 1 in 6. By 2050 it will be 1 in 4. There are 1.5 million people over 85 in the U.K today. 
  12. The NHS buys many drugs from Europe and the USA paying in Euros (€) and US dollars ($).
  13. Health tourism, foreign citizens using the NHS, costs the NHS an estimated £1-300 million per year. A new overseas surcharge recouped £289m in 2015. This is 0.3% of the total NHS budget. 
  14. Stationery costs the NHS £146m/year. 
  15. Compared internationally the NHS achieves above average outcomes, with average funding and below average staff numbers. OECD.
  16. Health costs rise each year in developed countries, above real world inflation. This is broken down into staff wage inflation, new technologies, population growth, new drugs and medical advances. 
  17. The NHS was estimated to require £30 billion by 2020 to meet predicted demand. To date, it has received £4.5 billion. 
  18. Social care is estimated to require £4 billion by 2020 to maintain current service. 
  19. The ratio of people working to those retired is called the Old Age Dependency Ratio (OADR). This was steady at around 300 retirees for every 1000 people working from the 1980s to 2006, but has now since started to rise. With retirement age changes, it will still increase by 20% by 2037 to 365.

So 1 in 6 of the UK population [1] is over 65 [11] at a healthcare cost in this group averaged at £3750 per year [10]. That’s 10.8 million people, which is £40.5 billion a year. The 1.5 million people over 85 require £11.25 billion a year. 

As the ratio of working people to those retired increase [19] and the population age [11] these costs will climb. Over the next twenty years these numbers will double, as the baby boom generation of post-World War Two retire and age.

Now for some opinions. Let me be clear. I’m not “blaming” old people. [https://mobile.twitter.com/kthopkins/status/819897520457392129] I’m talking about my father (77), my grandmother (82). These are people I love and care about. Day in and day out I look after their generation, and I see a system failing them, and not facing up to realities or requirements to provide them the care they deserve.

In healthcare the failings in one area tend to domino into others. As GPs close at record rates [2] and social care is progressively cut back [17] the burden on hospitals is doubled- both at the front end admitting unwell patients from the community and at the back end attempting to safely discharge them.

Unfortunately this is not how we are looking at the situation. 

Immigrants I hear you say? Back to some facts.

The median age of a recent U.K. migrant is 26, compared to the median national age of 40. [9] The average annual cost of a 26-year old in terms of healthcare is around £900. Which makes sense- how often does the average twenty old see the doctor? I went to the GP maybe three times in my twenties. The population doesn’t utilise healthcare equally, which is exactly why the NHS funding model works at all. 

I’d be remiss to not mention the other side of the equation; the large migrant population that work for the NHS. The NHS is the world’s fifth largest employer, employing 1.3m people. [7] 19% of all staff are non-British, 29.3% of doctors and 21.2% of nurses. [8]. 

Which is a good time to mention Brexit.

Applications for EU nurses have dropped , record numbers are leaving, and the NHS buys a lot of drugs from the continent in Euros (€) [12], which now cost more at current exchange rates. Additionally the NHS loses income from research subsidies to NHS hospitals and staff from the EU. 

But at least we’ll save money on health tourism? Right?

Health tourism costs £1-300m a year to the NHS [13] which is just 0.3% of the total budget. [2] In 2015 a new overseas surcharge recovered £289 million from this group. The aim of the surcharge is to make £500 million for the NHS by 2017, a £200 million profit.

So in summary it’s not about immigrants, it’s about realistic planning for the NHS to continue its excellent work as the population demographic changes. 

The NHS consistently achieves above average health outcomes for below average staffing per population and average OECD funding. [15] Although it may not seem like it, on a healthcare system level it’s one of the most efficient in the world. 

So is it failing? These are the facts.

GP waiting times are up, A&E [5] and elective surgery times [6] at record waits, while the NHS recorded its largest ever deficit last year, £2.45 billion in the red. The NHS is about £25.5 billion short of cash right now [17]. 

I’ll leave you to make your own opinion on that.

Lastly healthcare costs rise year on year regardless [16] which is known as health inflation.  While this means healthcare gets more expensive, it’s also part of the reason life expectancies have risen across the developed world for the past fifty years.

So what will change things? 

Well for the long-term future we have a smaller number of people paying for the healthcare of a larger retired population. We can address this meaningfully in one of three ways;

  1. Raise retirement age. Unpopular yes, but I’m talking about my own retirement here. Supporting this with aggressive public health improvement would be sensible.
  2. Have more babies. The low birth rate of the 1970s shifted the OADR in the wrong direction. To restabilise the ratio we need more young people. 
  3. Increase immigration. Unpopular again, but still correct. Immigrants come with an education (80-90% of recent immigrants have completed full-time education vs 50% UK average) [9], low health costs for their working lives, and more likely to retire back to their origin countries. The Office for Budget Responsibility agrees – the public sector debt by 2050 is predicted to be 145% of GDP, but with immigration, 120%. 

A combination of all three is probably needed.

In the short term your opinion may not have changed. But if it has, there is really only a single fact that will change the situation. That’s your vote.

Write to your MP, handwritten is best. Find their address here.

“Dear Sir/Madam,

I want this government to prioritise and fund the NHS. I hold you personally responsible for it’s failings and will vote accordingly at the next general election. Please act wisely.”

Yours faithfully,
[Your Name Here]

But that’s just my opinion. 

Juniordoctorblog.com

References
Fact 1 https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/articles/overviewoftheukpopulation/mar2017

Fact 2
http://www.gponline.com/nearly-200-gp-practices-closed-2016-alone-nhs-data-suggest/article/1421367

Fact 3, 4 and 7
http://www.nhsconfed.org/resources/key-statistics-on-the-nhs

Fact 5
https://www.google.co.uk/amp/www.independent.co.uk/life-style/health-and-families/health-news/nhs-crisis-a-and-e-waiting-times-record-levels-leak-bbc-data-government-failing-to-grasp-seriousness-a7570791.html%3Famp

Fact 6
https://www.patients-association.org.uk/wp-content/uploads/2016/11/Waiting-Times-Report-2016-Feeling-the-wait.pdf

Fact 9
http://www.cream-migration.org/publ_uploads/CDP_22_13.pdf

Fact 10
https://www.google.co.uk/amp/s/amp.theguardian.com/society/2016/feb/01/ageing-britain-two-fifths-nhs-budget-spent-over-65s

Fact 11 https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/articles/overviewoftheukpopulation/february2016#how-are-the-characteristics-of-the-uk-population-changing

Fact 13
 https://fullfact.org/health/health-tourism-whats-cost/
https://www.nao.org.uk/wp-content/uploads/2016/10/Recovering-the-cost-of-NHS-treatment-for-overseas-visitors-Summary.pdf.

Fact 14
https://www.nao.org.uk/wp-content/uploads/2011/02/1011705.pdf

Fact 15
OECD. http://www.oecd.org/els/health-systems/health-data.htm

Fact 16
https://juniordoctorblog.com/2016/01/05/its-the-spin-that-wins/

Fact 17
https://www.parliament.uk/business/committees/committees-a-z/commons-select/health-committee/news-parliament-20151/spending-review-health-social-care-report-published-16-17/

Fact 18 https://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/Budget%20briefing%20July%202015%20final_0.pdf

Fact 19
http://visual.ons.gov.uk/uk-perspectives-the-changing-population/

The NHS underfunding is a choice. And people are dying. [video]

It’s really hard to capture and keep even the most interested and motivated persons attention long enough to explain how and why the NHS is being underfunded and the truly catastrophic impact of this.

This rather excellent video series does this perfectly. 

Share and RT, write to your MP. It’s your choice too; stand by and let the NHS die, or do something about it. 

Gagged and bound. NHS doctors today.

“The airline industry has learnt that pilots must feel they can speak out”

Jeremy Hunt, May 2016

Imagine this.

You are a doctor, resident in hospital, not quite a consultant. You are employed by the hospital, but you rotate through different areas and different hospitals to broaden your experience of different practices. This is designed to make you a better, safer doctor.
One day you come to work, and find you are the only doctor working- there is no one else rota’d to be there. You have to look after your own hundred patients, but now you need to look after two hundred more. You are desperately worried this is not safe. People might get hurt.
As you have been taught to do, as a doctor and a hospital worker, you raise the alarm. You phone your bosses and tell them, you phone their bosses and tell them too. You try your best to keep people alive.
A few months later you sit down with your bosses, and they feel you harmed the reputation of the hospital. They sack you. Not just from that job, but from all training. In a single swipe, your career is over.


Fair? No. Safe? Definitely not. Legal? Surprisingly, and reprehensibily, yes.
At least according to a similar recent legal case against a junior doctor, Dr Chris Day, that decided that the sacking of a doctor for raising alarms over patient safety, for refusing to cover up negligence and potential harm to patients, is not only legal, but a ‘conscious choice of parliament’. The case is currently going to appeal in the Court of Appeal.
Does that sound right to you? As a patient? As a taxpayer? Your health service, at the absolute frontline, is staffed by junior doctors. These are the doctors that see you when you walk in the door, they will see you every day in hospital, they will do your surgery or keep your lungs breathing for you, they will resuscitate you if your heart stops beating. If there’s something wrong, you can guarantee, a nurse or a junior doctor will see it.
Legally- the hospital can’t sack a doctor for speaking up there and then. But doctors in training rotate department every 4-6 months and rotate hospital nearly every year. There is nothing to stop a ‘troublemaking’ doctor who points out dangerous care from having their career ended as soon as they move on to their next placement. A legal loophole, so dangerous it could swallow the entire NHS.
This has huge implications. Now we know this, many doctors, myself included, would think twice about speaking out. That in itself is a crime. We have mortgages and families- our livelihood cannot rely on the goodwill of pressured hospital managers. If a manager decides to, they can end your career, without recrimination.
I’d like to say the BMA and the GMC would step in to protect a doctor in this situation. The BMA proposed a clause in the new contract to cover this, but it’s legally flawed. The GMC have just been taken over by the department of Health, a conflict of interest in the making.

I’d like to say the Health Secretary, with his long term obsession with ‘whistleblowing’ and patient safety would help- but he himself spent taxpayer money cementing this loophole, keeping junior doctors vulnerable to dismissal for raising alarms.

How has this happened?

Well, all roads lead back to the government appointed body called Health Education England. Trainee doctors are employed by hospitals but hold a general training ‘number’ with HEE that delivers the doctors training over years, and partly pays their salary to their rotating hospital. This arrangement means they aren’t technically covered in law as our ’employer’, so can act with impunity in dismissing whistleblowers.

Funnily enough this is the same ‘training’ body that is threatening hospitals to cut funding for junior doctors if they don’t impose the contract upon them. This is how Jeremy Hunt dodged the legal challenge against imposition- by passing the buck, once again, to an organisation that can’t be sued, currently outside employment law. Proving they are legally our employers, as Chris Day is arguing, may have huge implications for further challenging the ‘imposition’ of the junior doctor contract.


Throughout this year we, as trainees, have fundamentally lost trust in the system. Through incidents like this, through the junior doctor contract dispute, through the years of increasing pressure on resources, target chasing and being ignored.
We have lost trust in the structures that run the NHS and their heads- Health Education England has proved it is neither interested in the ‘education’ of its members nor the ‘health’ of the patients they protect.
As long as we don’t get sacked, we won’t be ‘junior’ doctors for long. In time we will all be your consultants and GPs, the clinical leaders of the NHS. What then? Will we still carry a culture of fear and denial, instilled in us by a system that’s supposed to train and nurture us? Let’s hope not.

The future of a safe NHS depends on it. If you want to do something to safeguard that future, donate to Dr Chris Day’s legal fund here. He needs to raise £100,000 to continue his fight for whistleblowers everywhere.

Help make sure his voice, and all of our voices, are heard.

Juniordoctorblog.com

The future of the NHS and junior doctors is bleak. Can we change it?

It’s clear, despite widespread junior doctor support for further reasonable industrial action against imposition, that the BMA has folded. Now in full “supporting transition” mode, the early imposed trainees already report chaotic rotas, trusts skipping pay protection clauses and lack of coherent safety reporting structures. Many doctors have left, or are considering leaving, the BMA.

Obviously into the midst of this Jeremy Hunt puts the boot in. Keen to build on the perceived political capital of pushing the BMA into withdrawal and supposedly ‘winning’ his High Court case against the contract, he goes onto announce plans to chain doctors to the NHS for four years after qualification, and to replace the ‘foreign’ doctors that prop up the NHS as it is, with ‘homegrown’ doctors.  His plan to expand medical student places by 1500 a year starting from 2018 isn’t unwelcome – it’s just dangerously unrealistic and overtly xenophobic. Doctors entering medical school today will enter the workplace, chained to the NHS, in 2021/22.

What will life be like then?

Hospital Activity
It’s fairly straightforward to extrapolate UK demand by 2022, and the Nuffield Trust have already done the work [ref]**. They report from 2014 predicted NHS demand, expressed in bed days, will roughly rise by 1.7%/year. That means by 2020/21, demand will have risen by 8.7% and by 2021/22, 11% compared to today.

Funding

By 2021, bar any dramatic announcements in the Autumn statement, the King’s Fund predict NHS funding in real-terms will rise by £4.5 billion, a rise of 4%. However, the current deficit this year is £1.8 billion, so this is actually just £2.7 billion to spend, a true rise of just 2.3%*.  Meanwhile, hospital demand will have risen by 2020/21 to 8.7%, which means each extra pound will need to work four times as hard just to stand still. Given waiting times in A&E and surgery have never been longer and the current deficit is the largest ever recorded, the system already appears to be stretched to crisis point.  Imagining it can now stretch to accommodate an efficiency of four times what it currently  can achieve is lunacy.

This prediction also relies on being able to discharge patients, reducing pressures on hospital, but social care has also had it’s funding slashed, back to just 0.9% of GDP by 2020, with an estimated shortfall there of £3-3.5 billion. It’s not going to get better.

Hospital bosses know this, and have already spoken out. NHS Providers CEO Chris Hopson and NHS Chief Executive Simon Stevens have both said current funding is unsustainable .

What will that look like on the ground? Well, resources will be diminished, pushing people out of hospital beds will become more commonplace, and with no staff budget more and more hospitals may have to close departments due to lack of staff to run services safely. Here is a list of sixteen hospital departments that have closed this year. Expect this to grow. This might mean working in hospitals without services on site, sending patients miles away and arranging urgent transfers to other hospitals, which is less safe, and very time-consuming, to already overstretched staff.

Training/workforce

As of 2015, there were 41,165 consultants and 36,919 GPs in the NHS,  plus 54,000 junior doctors, with 25% of them trained overseas, either EU or non-EU. For GPs and consultants, the NHS plans to increase this by 5000 a piece, or 14% by 2020. However, new workforce modelling predicts we may need as many as 12,000 more GPs to run a thread bones service, and 24,000 to run a safe and well staffed one.

I can’t find the numbers of junior staff required, but if we simply match demand in 2024, 14% compared to today, the ‘extra’ doctors would need to be 7560 more than today. It would taken ten years to catch up to demand, by 2034. That’s a huge deficit to walk into.

There’s of course a plan to expand the numbers of non-doctors to fill the shortfall;  non-medical endoscopists, surgical assistants, physicians assistants are all already active in the NHS. What this will mean for junior doctors is hard to gauge – it may help training, it may hinder, and a lot of work will need to be done to work out how workplace issues such as medicolegal responsibility and training will be impacted by the increasing use of non-medical staff doing work previously done by junior doctors.

And that’s of course assuming all the ‘foreign’ doctors are allowed to ‘stay’. Theresa May claims they can stay until at ‘least’ 2025, but why would they? If even 10% of the overseas trained doctors left the NHS in the next ten years, it would be utter cataclysm.

Morale

Needless to say, being chained to an organisation for four years, that requires you to stretch four times more work out of it’s resources compared to today, that’s missing thousands of staff, with hospitals in various states of closure, might dampen morale.

The imposition of the new contract for junior doctors of course will only make all of this worse. As budgets are tightened further cuts will need to be made to staff groups – the strikes this year will be far from the last to hit the NHS.

NHS

Ultimately all of this speculation relies heavily on the idea an NHS will still be the main provider of healthcare in the UK by 2024. Looking at the staffing, financial and patient demand projections, no credible plan emerges to preserve the NHS. Services will slowly degrade, and more and more private options will come available. Already a private Uber-style service is emerging into the current GP crisis. This could be the snowball that starts the avalanche, as more and more wealthier citizens are pushed towards private healthcare.

My point here is the battlefield ahead is perilous, for patients and staff, as we are guided by NHS bosses that are unheard and ministers either deliberately or incompetently steering us towards rocky shores. Whatever Jeremy Hunt’s plans, 1500 doctors a year will not make any impact whatsoever in 2024, far from being ‘self-sufficient’, and we will have huge crises in senior staff and resources that no amount of fresh-faced ‘homegrown’ graduates will solve. If our hardworking and invaluable overseas staff leave, the NHS will collapse instantly.

 

That’s the future of the NHS and junior doctors – bleak isn’t it?

So what are you going to do about it?

juniordoctorblog.com

 

*This assumes there will be no deficit for the next three years – an extremely tall assumption. More likely, there will be no extra money whatsoever.

**barring some huge paradigm shift in medicine, or an epidemic disaster. Brexit may count in this respect – the fall in the pound vs the Euro has made medicines more expensive, and the loss of research grants has made teaching hospitals poorer.