Brexit and the NHS: Just the Facts. Part 3: We, The People

In a multi-part series juniordoctorblog.com looks in-depth at the potential impact a No Deal Brexit will have on the NHS. In Part 1, we looked at the potential disruption to the supply of vital medicines, and in Part 2 we examined the barriers to importing nuclear isotopes essential in many treatments including cancer.

In this part we look closely at the largest and arguably most important resource the NHS has, the staff.

What’s going on with NHS staffing in 2018?

The NHS is the world’s fifth largest organisation, in England alone it employs 1.2million people. Since 2010 staff numbers across multiple areas have fallen, leaving large gaps. To maintain current services we need 40,000 more nurses, 10,000 more GPs, 11,000 more hospital doctors and 7000 more mental health nurses.

What has the government done about this so far?

Short answer: A lot of words and little else.

Long answer: During the coalition years the government cut nursing training numbers and nursing staff posts in hospitals, as well as cutting 6000 mental health nurse positions. Meanwhile demand and activity in the NHS relentlessly grew every year by ~3%, increasing the pressure on the remaining staff and creating a situation where more staff are leaving than joining.

Despite promises of “5000 more GPs by 2020”, the number of GPs have actually fallen by over a thousand. Growth in nursing numbers is equally negative, as more leave the NHS than join. Despite proposing 15,000 more nursing places to train “homegrown” staff, so far those extra places have not been filled. Funding for places may have increased but bodies have not followed; applications fell by ~10,000 in England last year, meaning the number of nurses in training actually dropped. This is due to the government cutting nursing bursaries and charging full tuition fees from 2016. Similarly, the government has announced an expansion of doctor training places by 1500 per year from 2020, but these new doctors won’t be on the shop floor until 2025, and won’t be new GPs until 2030 or new hospital consultants until 2033.

What has that got to do with Brexit?

We have a worsening staff crisis coupled with a failure to train our own staff to deal with it. We are therefore 100% reliant on recruiting trained staff from abroad to fill the gaps, in recent years from the EU especially. Of the NHS 1.2 million staff, approximately 5% are currently from the EU, 10% of doctors and 7% of nurses.

How have things changed since the Brexit vote?

The official number of self-reported EEA staff has actually risen slightly from 58,698 to 61,974 between 2016 – 2017. This is partly because 10,000 “unknown” nationality staff members in 2016 became “known” in 2017. In specific groups, such as nursing, there has been an 89% drop in the number of new EU nurses, and a 67% rise in those leaving.

Are EU staff leaving?

Short answer: Yes

Long answer:

Staff in the NHS come and go as with any very large organisation, it’s the relative balance that is important. The total percentage of EU staff leaving has increased, and the percentage of EU staff joining has decreased. 10,000 EU staff left the NHS last year, an increase of 42% on the year before.

The BMA surveyed 1700 EEA doctors this year- 50% were considering relocating, and 20% had already made concrete plans to leave. Although this is bad, the major issue is recruitment.

Since 2016 EU recruitment has flatlined, for nurses especially. In addition to new language tests, new EU nurses also face a falling exchange rate, dropping the effective starting salary by 12%, and prolonged uncertainty about their working conditions and residential status. Applications for EU entrants into nursing have dropped 96% since Brexit began. Where 6400 new EU nurses joined in 2016, only 800 joined in 2017, a loss of 5400 nurses we sorely needed. The number of doctors also joining the register from the EU declined by 1000 between 2016-8.

Overall since 2009 there has been a steady rise in nursing and medical staff from the EU, a rise which levelled off after the EU referendum and hasn’t resumed. The balance of recruitment to resignations has shifted dramatically, so as a source of manpower to solve our staffing crisis the EU has dried up.

Why is this a big deal? What’s a few less nurses?

Statistically there is a direct correlation between staff numbers to patient ratios and the chance of survival. For example, the higher the number of nurses per patient the more likely stroke patients are to survive. Less staff = more deaths and more patient harm. The NHS recruits in large drives to plug these gaps from the EU; Spain, Portugal and Ireland in particular, but no longer. That shortfall will undoubtedly lead to patient harm.

How does No Deal change any of this?

The No Deal Brexit papers specifically do not mention EU citizens status in the event of No Deal. Whether a tactical omission or a political misstep, the lack of concrete reassurances for EU staff is deeply troubling. Bear in mind many of our EU NHS staff have lived here for years, have children in schools, support dependent relatives and have long-term careers. The looming threat of uprooting and even deporting, however distant or vague, should not be underestimated. If you were in the same position of uncertainty, unsure if you might have to pack up your whole life in six months time, would you buy a house? Would you move to a new job? It seems unlikely you’d come to a country that was so unsettled currently.

The additional predicted further drop in the value of the pound, the uncertainty over basics like pensions and healthcare access in the event of No Deal, will only compound that. As a father with a young family I certainly would not move here if I were in that position, and I can’t say I wouldn’t be thinking of leaving myself. Would you?

Is the government doing anything about this?

Dominic Raab, the current Brexit Secretary, has “reassured” EU residents no one will be “turfed out” in the event of No Deal. However, as already mentioned, they haven’t published anything tangible on this as yet.

There is a pilot programme in the North West for up to 4000 EU students and NHS staff to apply for Settled Status, initially for those in 12 NHS trusts. Although a digital process this pilot will require a face to face Home Office appointment. The Home Office has already stated it does not have sufficient staff currently to process 3,000,000 applications, and the initial launch of the “app” in June did not function on half of smartphones, so it remains to be seen how the remaining 60,000 NHS staff will be settled in this way. Whether these terms will change in the event of No Deal is another question hanging over everything.

What about future EU recruitment for the NHS?

The drop in recruitment due to Brexit is creating a worsening shortfall in key departments, increasing the pressure on existing staff and exacerbating increased numbers from all groups leaving the profession or retiring early.

In a No Deal Brexit the U.K. remains a less attractive destination: relatively less pay, new barriers to the immigration process including visa caps as a third country and uncertain settled status.

So in summary the NHS is already in an understaffing crisis, created by under-resourcing and poor workforce planning, exacerbated by cuts to posts and bursaries for recruitment, meaning hopes of new “homegrown” staff to plug the gaps are a decade away. EU staff have been invaluable to maintaining a functioning service but since the Brexit referendum recruitment has dropped off a cliff. A No Deal scenario will only compound the haemorrhaging of staff, in a system where staff numbers are a literal matter of life and death.

With a shortage of medicines, diagnostic isotopes and vital staff, we will require a massive influx of resources and funding to keep the service going.

Resources and funding we do not currently have. If you’re still with us, read on to Brexit and the NHS: Just the Facts. Part 4: Show Me the Money. (coming soon).

Juniordoctorblog.com

References

http://www.pulsetoday.co.uk/home/finance-and-practice-life-news/at-least-12000-new-gps-needed-by-2020-new-workforce-data-reveal/20032973.article

https://improvement.nhs.uk/documents/2471/Performance_of_the_NHS_provider_sector_for_the_month_ended_31_December.pdf

https://fullfact.org/economy/pound-fallen-since-brexit/

https://www.nursingtimes.net/news/workforce/nurse-patient-ratio-found-to-be-key-to-stroke-survival/7012974.article

https://www.bma.org.uk/news/media-centre/press-releases/2017/november/almost-a-fifth-of-eu-doctors-have-made-plans-to-leave-uk-following-brexit-vote

https://researchbriefings.parliament.uk/ResearchBriefing/Summary/CBP-7783

https://fullfact.org/health/eu-nurses/

https://www.health.org.uk/chart-large-drop-number-new-nurses-coming-eu-work-uk

https://www.bma.org.uk/-/media/files/pdfs/collective%20voice/influence/europe/effect-on-the-nhs-of-the-uk-leaving-the-eu.pdf?la=en

https://www.bloomberg.com/news/articles/2018-02-15/european-doctors-are-giving-up-on-the-u-k

https://www.careappointments.co.uk/care-news/england/item/44896-nursing-in-managed-decline-as-new-figures-show-further-drop-in-student-numbers

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Brexit and the NHS: Just the Facts. Part 2: Going Nuclear

In a multi-part series juniordoctorblog.com looks in-depth at the potential impact a No Deal Brexit will have on the NHS.

UPDATED with the latest No Deal planning paper from Govt. “Civilian Nuclear regulation if there’s no Brexit Deal”.

In Part 1, we looked at the potential disruption to the supply of vital medicines. In this part, we will look closely at the use and supply of radioactive isotopes in the NHS, and how a No Deal Brexit specifically will impact this.

What do you mean radioactive?

We use radiation a lot in medicine. The term conjures images of radiation burns and nuclear warfare, or perhaps super-powered arachnids, but in controlled doses for the right reasons radioactive substances are a vital part of many types of healthcare. We can use radioactive therapies to diagnose conditions, monitor treatment, and even as treatment itself. From breast cancer to heart disease to thyroid cancer there are dozens of uses for nuclear derived radioactive material.

Where does it come from?

Nearly all nuclear material for medicinal use is imported. The commonest, Technetium-99m, is made in several reactors in Europe. We perform over 600,000 radioactive imaging procedures a year involving Tech-99m alone. The production, transport and storage of radioactive material is obviously very heavily regulated. The agency responsible in Europe is called EURATOM.

What is Euratom?

The European Atomic Energy Community is responsible for the safe use and distribution of all nuclear material- from the tiny diagnostic isotopes we use, to the nuclear reactors that generate power for cities. Unlike the European Medicines Agency, we currently do not have a local equivalent in the U.K.

Why is that important?

Well, in a No Deal scenario we have no equivalent agency of infrastructure to manufacture, import and export, distribute and store, radioactive isotopes.

UPDATED: in the latest government technical paper on civilian nuclear material, responsibility will move to the Office for Nuclear Regulation. Importing nuclear materials, as with medical isotopes, still has no plan at this time. Under the relevant header the paper reads: “importers may need to obtain an import license” and will “provide further guidance” at an undisclosed interval. So, still no plan as yet.

The Lords voted to stop our withdrawal from EURATOM in 2018, but a No Deal scenario would leave us out regardless. The rationale for leaving EURATOM as its “legally joined” to the EU has been derided as dubious as best. Currently it’s unclear what will happen in any Brexit scenario.

To illustrate the potential impact on the individual let us look at a specific example: the use of Technetium-99m in breast cancer, in a technique called Sentinel Lymph Node Biopsy. When diagnosing breast cancer we need to know several things: is there a tumour there, how far advanced are the cells in the cancer process, how far it’s spread in the breast itself and how far it’s spread to other places, firstly the lymph nodes in the armpit. These ‘sentinel’ nodes play a huge part in prognosis, and determining the need for chemotherapy and radiotherapy. Sentinel Lymph Node Biopsy uses radioactive isotopes to very accurately diagnose cancer spread to the armpit, determining the need for chemotherapy and radiotherapy. Without the isotope the potential to miss spread to the armpit skyrockets, as the next best diagnostic test is far more likely to make a misdiagnosis. Missing spread and reducing treatment means a curable cancer could become an advanced one, or even a deadly one. These are the stakes at play here.

Have these isotopes ever run out before?

Yes. There was a series of reactor maintenance stops in 2008-9. At the time there was sufficient supply for most units to delay or borrow isotopes from other hospitals. There is also a predicted shortage from 2016-2020.

Why is No Deal Brexit different?

The scale of the issue this time has never occurred before. Additionally the new requirement for customs infrastructure will have major implications as these isotopes cannot be stockpiled- they decay to become non-useable after a number of weeks. Procedures such as thyroid cancer treatment, palliative treatment for bone pain and heart scans would all be halted, temporarily or even long-term while inferior alternates are used.

in summary, leaving EURATOM does indeed appear to be the nuclear option: it’s needlessly extreme with no legal basis and will have widespread and long-lasting ramifications. There’s a high probability you will personally know someone who will be negatively affected. As a doctor, I have to admit I didn’t know most of this a year ago. I’m flummoxed how anyone outside of the industry could have. None of us were “informed”. Until now.

With less medicine and no isotopes we face a rocky future in the NHS. None of that will matter however without any staff.

See Part 3: We, The People (Coming soon)

References

https://researchbriefings.parliament.uk/ResearchBriefing/Summary/CBP-8036

https://arxiv.org/pdf/1501.03071

https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX:12012A/TXT

https://www.cancer.gov/about-cancer/diagnosis-staging/staging/sentinel-node-biopsy-fact-sheet

https://www.gov.uk/government/publications/civil-nuclear-regulation-if-theres-no-brexit-deal/civil-nuclear-regulation-if-theres-no-brexit-deal#nuclear-safeguards

Brexit and the NHS: Just the Facts. Part 1: Medicine

In a multi-part series juniordoctorblog.com looks at the No Deal Brexit scenario and its direct and indirect impact on the National Health Service.

Informed consent is the bedrock of medical ethics. It means I cannot legally do anything to you without your express permission, and for anything you do allow, or “consent to”, you have to know why you need it, the risks, benefits and all the alternatives. Such are the legal ramifications of this, if I were to perform a procedure without properly informed consent I could be jailed for the crime of battery.

The absolute irony of the EU referendum, arguably the most important vote in a generation, was the completely backward approach to the decision. The further from the time of “consent” the more informed the conversation has become. In this first part juniordoctorblog.com asks, how will a No Deal scenario affect our supply of drugs and medicines?

Will we still be able to import medicine?

Short answer: Yes, but costs will likely rise, and some supply chains will be threatened or may breakdown entirely.

Long answer:

Currently there are no tariffs or border checks within the EU for medicines. Tariffs are additional duties charged at the border for moving medicines between countries.

In the event of No Deal we would leave the EU and become an individual state within the World Trade Organisation, an internationally agreed baseline for trading.

The WTO has its own issues:

1. Although we are currently members our membership is within the EU bloc. We don’t have individual membership yet.

2. The WTO court for settling disputes is currently non-functioning due to a dispute with the USA. If any aspect of our joining or terms is disputed, there isn’t currently a way to settle it within the WTO.

Specifically in regards to moving medicines back and forth between the EU from the WTO, the EU is signed up to the Pharmaceutical Tariff Elimination Agreement, an Agreement to eliminate tariffs on a set list of medications with other WTO countries. We could continue to import tariff free medicines on this list from the EU under this agreement. However, this list hasn’t been updated since 2010- the US are again disputing it and holding up a revision. This leaves many new medicines off, meaning we would have to pay new tariffs on importing those from the EU. Which is a lot. We import 37 million packets of medicines every MONTH from the EU worth £18.3billion. The EU are our largest source of medicines (73% of all our imports), likely due to the frictionless movement and lack of tariffs. Estimated WTO tariff rates would add 5-6% of cost to these medicines. We also leave all the EU-WTO countries Free Trade Agreements we also had access to, e.g Japan, and any agreed medicines tariff reductions included in them.

Worse, UK based companies produce medicines in supply chains that often cross borders multiple times – each import potentially adding an additional tariff without an agreement. This will add significantly to the current £16bn medicines bill for the NHS.

That’s just the additional taxes. The costs and practicalities of physically moving medicines across customs borders will be a huge barrier to importing medicines, so-called “non-tariff barriers”. These govern how medicine is checked, regulated and transported – essentially guaranteeing the drug that’s injected to you has for example been refrigerated across the entire supply chain so it remains safe. Or is actually the drug on the bottle and not a knock-off imported elsewhere.

If we leave with No Deal we also leave the Customs Union, meaning we will require infrastructure at our border and at every exporting countries border to facilitate movement of medicines between our countries.

Not only will this disrupt and delay the import of finished medicines to our hospitals, it will also disrupt our ability to make medicine in U.K. based pharmaceutical companies like AstraZeneca and GSK. Many of these supply chains are time and temperature sensitive. Delays at borders may break the chain entirely and strategies to circumvent these issues, such as building additional storage space, additional supply routes or moving manufacturers, will only add to the final cost of the medicines passed on to the NHS.

Many drugs we also can’t stockpile for very long to prepare for a No Deal scenario. Insulin is a good example. We only make 1-2000 patients worth of insulin in the U.K. each year, while the national need for the medicine is 400,000 patients, the vast majority imported from Europe. We can’t stockpile insulin for very long, and it requires refrigeration and very careful regulated transport.

So, back to our short answer, availability of medicines will be reduced due to customs delays and supply chain issues, while the cost of these new barriers will be added to the medicines alongside any new tariffs for medicines off the list of WTO traded drugs. If this adds even a conservative 8% to the cost of medicines, that means an additional cost to the U.K. of £1.4bn every year.

What about importing future medicines?

Short answer: Leaving the European Medicines Agency will add to the cost of introducing new medicines to the U.K., deprioritising the U.K. for new drugs and delaying the introduction of state of the art therapies, such as in cancer.

Long answer:

Even if we can secure the supply line for our existing medication, in the short to mid-term we will face difficulties bringing new medications to the U.K. We were previously a key member of the European Medicines Agency, an organisation governed by the European Court of Justice. This Government decided Brexit should include leaving the EMA as it’s under the jurisdiction of the ECJ, although passed a motion this summer to include negotiating to stay in the EMA as a non-member. Obviously in the event of No Deal we are out of this entirely.

Why does this matter?

The process to develop new drugs and medicines is unbelievably expensive and time consuming. New medicines have to first be synthesised, tested on cells, then animal models and then a dose and formulation needs to decided upon. That process alone can take a decade and often doesn’t go anywhere at all. Once a drug is stable and theoretically beneficial to humans it has to go through several phases of trials before it can be approved for routine use by any doctor for a patient. Firstly it’s tested for safety in healthy people- unforeseen severe side effects in humans sometimes occur, for example see the “Elephant Man” trial at Northwick Park Hospital in 2006, where six healthy adults took an experimental drug at this phase of testing and all become critically unwell. Once it passes this safety benchmark the drug is then tested in a small group of people who actually have the disease. This is to demonstrate benefit and look at side effects- again, in the real world this may not work at all. If it passes this stage a much larger trial is organised, usually testing the drug against a placebo or the current best treatment in the strictest conditions possible to avoid any possible corruption of the results. These large trials take years to organise and perform and then publish, cost millions of pounds and again, often don’t go anywhere at all. Even once a drug is in the market we have a phase 4, where data is continuously collected from reported side effects. Sometimes it takes two or more of these trials to prove something actually works.

You can see already what a time-consuming and data-heavy undertaking this is. The EMA’s job is essentially to check every stage of this process, to take into consideration of practicalities like how the drug is given and how much it costs, and then to approve and regulate the medicine for use in EU patients.

Without this function there would be no checks on the drug development process, a process already hugely driven by the need for pharmaceuticals to recoup the money they’ve spent on development.

The EMA streamlines this process for the U.K. by allowing a single member state to undertake the approvals process and then applying that approval to all other members. So a drug approved in France is then licensed for the U.K.

Our subdivision, the Medicines and Healthcare products Regulatory Agency, was a leading part of the EMA. EMA HQ was formerly in London, and employed 900 people, but has already moved away post-Brexit vote. Once we are out of the EMA we will have to approve and license every new drug ourselves. As a much smaller market for drug companies than the EU we will be deprioritised for new drug launches. State of the art developments for conditions like cancer will take longer to come here. This might seem a trivial concern; what possible difference could a year or two make for a single drug?

In the 1960s an accidental discovery created an entirely new cancer drug called Cisplatin. Based on platinum, Cisplatin was found to be revolutionary for the treatment of testicular cancer, a condition that was once fatal in nearly all patients, but is now cured in 90%.

Imagine you have been given a terminal diagnosis, perhaps a year to live, when a new game-changing medicine like Cisplatin is discovered. Those few years delay will make the difference between life or death for you. That’s the reality of the unforeseen consequences of such a colossal decision; the knock-on effects domino everywhere, and real people may actually die as a result.

So, leaving the EMA will add to our own development costs and time requirements to approve medicines and delay state of the art treatment in conditions like cancer, where time can make all the difference.

What about future medicines?

Short answer: We are pulling out of research funding and EU-wide scientific collaborations on health and medicine products, which may hamper potentially life saving medical advances.

The long answer:

In the mid to long term, threatening to pull out of the EU with No Deal has already dropped many U.K. applicants from the EU research fund, Horizon 2020. A half a billion pound fund backing health science and technology, we may never know what good that could’ve done, what avoidable harm will now happen as a result.

So a No Deal scenario will have far reaching and damaging effects across nearly every aspect of current and future medicines in the NHS?

Short answer: Yes

Long answer: Very much so. But it only get worse. See Brexit and the NHS Part 2: Going nuclear.

Juniordoctorblog.com

References:

https://www.cancer.gov/research/progress/discovery/cisplatin

http://www.pharmatimes.com/news/nhs_managers_warn_no-deal_brexit_risks_drug_shortages_1249697?utm_source=dlvr.it&utm_medium=twitter

http://www.pharmatimes.com/news/mps_vote_for_uk_to_remain_part_of_ema_1244680

https://publications.parliament.uk/pa/cm201719/cmselect/cmbeis/382/382.pdf

http://www.ema.europa.eu/ema/index.jsp?curl=pages/news_and_events/news/2018/08/news_detail_003005.jsp&mid=WC0b01ac058004d5c1

https://www.channel4.com/news/factcheck/factcheck-are-insulin-supplies-really-at-risk-from-a-no-deal-brexit

https://www.google.com/amp/s/www.bbc.co.uk/news/amp/magazine-35766627

“You are having a heart attack but we will fix it”. If only everything was so simple.

I’m working my second stretch of nights in a week (due to a missing EU doctor, ironically) on the heart attack service. At 3am my bleep rattles next to me and then shouts “Primary Angioplasty. Inferior MI. 10 minutes”.

This means someone is flying towards us in the dead of night with a major heart attack. Inside, a vessel supplying the heart muscle is completely blocked, the muscle beyond literally dying by the second. Needless to say these patients are very unwell.

The patient arrives and her ECG confirms all our fears: a major heart attack. My 3am brain tries to simultaneously take her history, listen to the ambulance handover, scan her heart muscle and consent her for the procedure all at once. She’s looking very unwell and I’m very conscious of how short time we have. “Time is muscle” in cardiology land, and her heart and possibly life is slipping away by the minute. 

I end up simply saying “You are having a heart attack, but we will fix it”. We rush her into the lab and fifteen minutes later we have indeed fixed it. She’s looking much better and is very thankful. I love cardiology.

Simple eh? From the patient’s perspective she’s had some chest pain, called an ambulance, been told she’s having a major heart attack, and then told it’s been fixed. What could be easier?

Well, pretty much everything. The procedure actually takes at least five people to perform properly, all highly skilled and trained and working together seamlessly. Every bit of equipment we use has been developed over decades, rigorously tested in trials involving 100,000s patients, each part carefully evaluated, checked, stored and audited. The techniques we use, even the pathway itself, has been researched and tried and rejected and trialled again. When this technique was first pioneered many thought it ludicrous. Now it saves thousands of lives every year. Even the basic physiology is incredibly complex.

Which is not to say nothing ever goes wrong- far from it. We routinely have patients who we can’t make better, or don’t get there in time, or need even more advanced therapies: pumps inside the heart, artificial lung and heart machines, emergency bypass surgery, even transplants. There is an entire world behind the curtain that very few members of the public will ever glimpse. And even those who do so directly as our patient do so with only the limited and reassuring perspective of a problem that has been “fixed”. With only a tiny cut 1mm long in their wrist, who can blame them?

Which, by a rather roundabout way, leads me to Brexit. Obviously. This week the NHS and Brexit have been in the news on multiple fronts, mostly raising concerns about the implications of No Deal on the NHS and then some unbelievable absurdity about shortening doctors training times after Brexit to “plug staff shortages”.

The issue we seem to have is one of perspective. There’s too little scrutiny, too much wilful acceptance of “I can fix it”, and not enough people asking “how?”. And especially not enough detail for those of us behind the curtain that can see the vast monstrosity of interlocking gears and cogs that makes up the NHS machine. For those of us that worry Brexit, especially No Deal, will be a sledgehammer to a system already straining under pressure.

Take for example the No Deal scenario. Overnight we will leave the Customs Union and European Medicines Agency, meaning importing medication will require new licenses and tariffs, infrastructure we don’t currently have. Insulin has been the much lauded example– used by nearly half a million patients in the U.K., only one small factory in the U.K. makes any at all, enough for 1500-2000 patients a year. The rest (99.9%) is imported from France, Denmark and Germany. On day 1, with No Deal, there would need to be additional customs infrastructure to even EXPORT to us. In places like Germany where there wasn’t before. The new Health Secretary, Matt Hancock, has assured us they are stockpiling for contingency planning for this event. But insulin needs to be refrigerated, and we are talking about half a millions patients a year. I want to see the detail, I want to see the benefits of this plan, I want to see the mechanics of the machine before I accept this is even possible. So far I have yet to be convinced.

Similarly, Steve Barclay, Tory Health Minister, made headlines on Friday claiming that Brexit will be good for the NHS, claiming the EU forces U.K. doctors to qualify in five years minimum and we could shorten this to “plug staff shortages”. But behind the curtain we know nearly all U.K. medical courses are five years already, some graduate entry courses are four years (although some have switched to five now) and count the first year of work as qualification to meet the EU technical requirement. We know we can’t shorten medical school beyond four years due to the sheer breadth and intensity of work, and the reason most U.K. medical schools opted for five years in the first place. This suggestion will have no practical impact on doctor numbers, but might make undergraduate medicine overly pressured or dumbed down, and will only affect <25% of graduates regardless. And no mention of the 10% of U.K. doctors from the EU who already risk losing their right to work, to healthcare and to pensions here in the event of No Deal. It’s this nonchalant and worse, unchallenged, Brexit commentary that doesn’t inspire confidence amongst medical professionals. We doubt that our government understands the dangerous and complex machine they are tinkering with. 

Similarly Theresa May proposed a welcomed £20bn injection of funds into the NHS, but then predicated that on a “Brexit Dividend”, a dividend nearly every single economist agrees doesn’t exist, a dividend for which no legitimate cases has been made. It’s hard to trust a government that seems to speak to us without any substance. No wonder a majority of U.K. doctors support a referendum on the final terms. 

In the healthcare profession we have a pathological abhorrence to unsubstantiated claims. To b******t. Colleagues that say they will do something and then do not are unreliable, and unreliability is dangerous. Bald-faced lying is even worse, and the GMC hold us to a standard far higher than any politician. A lack of basic probity will get you suspended or struck off, such is the bedrock of trust that the practice of medicine requires. Trust between ourselves and our patients, and trust with each other. And the highest sin of misinformation? Wasting the most precious resource we have; time. Time is muscle. Time is life. Time I waste with you I could infuse into someone else, time that could make all the difference. And for Brexit time is running out. 

Despite occasional appearances suggesting otherwise, medicine teaches you a universal truth: nothing is simple. Absolutely nothing worth doing is easy. The Brexiteers waving away the potential healthcare disasters ahead think they are riding a tricycle down a garden path, that they can flick a wrist and change direction on a whim, when really they are aboard a runaway freight train, heading for a cliff.

We need to start hearing some practicality, we need to start seeing some understanding of the complexity of the machine, of the extraordinary stakes ahead. We need less of the perception “everything is simple”, and more of the reality: this is complicated, this really matters, lives are literally in the balance.

Please fix it.
Juniordoctorblog.com

Family separation is beyond inhumane, this is state sponsored child abuse

My daughter’s first pair of shoes were a present from her aunty. A palm-width long, green-grey dotted with gold stars, white sole, single Velcro strap. She’d been running around with that manic toddler waddle for a while, the eye watering one where every step seems to just save them from face planting to the ground. Probably a little overdue, her shoes were an instant passport to a whole new world of roaming. She could now run unhindered in the playground, in the shops, down the street to her aunty’s house. As you can imagine her shoes brought her unfettered joy, the innocent happiness of a child. She loves her shoes, she grabs them at every opportunity and rushes to the door, even grabs my trainers and tries to put them on my feet if Daddy is too slow.
My daughter looks down at her feet in the exact same way the little girl in this picture does. Her mop of wavy dark brown hair looks just like hers. When she cries, my heart breaks. When I look at this little girl staring down at her shoes, and moments later crying for her mother, I see my own little girl. I cannot stomach it.

The US-Mexico border has been a contentious issue in US politics since before Trump began his populist anti-immigration drive that propelled him into the White House, but his ever-escalating rhetoric has led here. The chants of “build that wall” have morphed into a horrifying reality: children and even babies in actual cages. 

Despite the Trump administration protestations that “this is the law” the legal situation that has suddenly seen thousands of children taken into state custody and separated from their parents is not quite as simple.

Entry into the United States outside of a recognised port was previously prosecuted in civil court. Pre-trial incarceration used to be the exception, not the rule. Child caring responsibilities are supposed to be a mitigating circumstance AGAINST jailing parents. Children are only removed if there is concern they are being abused. Imagine being arrested pending trial for not paying parking tickets, your child forcibly removed to state custody, a state system without the capacity or will to reunite you. 

The decision to prosecute and hold both illegal entrants and asylum seekers as criminal cases, not civil, is the “zero tolerance” policy of Attorney General Jeff Sessions and President Trump. Children cannot accompany their parents to prison, so they are separated at the border, as stricken mothers and fathers are told their child is being “taken for a bath”. The next thing they are told is they won’t see them again. 

Why is the Trump administration pursuing a policy so inhumane and so cruel? A policy that has created a huge national and international backlash? The party line is “it’s the law”, or “it’s the Democrats law”. These are plain lies. George W. Bush signed the last legislation covering family separation for immigrants, passed overwhelmingly by both major parties. 

Looking beyond this front several officials have admitted this practice is a deterrent, deliberately punishing families that cross illegally. Punishing children, potentially irrevocably so.

Even worse, in response to the international outrage Trump has proposed any new legislation to end family separation is linked to funding for the US-Mexico border wall project. In other words, he will release the children when he gets his money. A United States President, holding children hostage.

At the same time Trump has announced they will pull out of the UN Human Rights Council. For an administration completely lacking in any humanity this seems appallingly appropriate. 

As a doctor, I know the physical and mental cost to the children who are put through such a trauma is heavy. The American Academy of Paediatrics has publicly condemned the practice, equating the psychological and developmental harm this causes to child abuse. 

As a father, I can’t stop looking at this picture of this little girl with her shoes. I cannot stomach the horrifying footage of children in cages. I cannot fathom how any human being of moral conscience cannot see the evil in this, or worse, try to defend it.

The American Civil Liberties Union is currently in the process of suing the government in a national class action suit to desist and reverse the policy of family separation. You can donate here.

President Trump will visit the U.K. in early July. If you believe this policy is a stain on any decent society, come to London or Scotland or wherever he scurries to and let him know.

My daughter’s shoes bestowed a gift of freedom and happiness. This little girl has neither. Our children will one day ask us where we were and what we did during this turbulent period in history. I want to be able to look my daughter in the eye and tell her humanity and decency prevailed because we stood up for it. 

So stand up.
Juniordoctorblog.com

The ambulance never came.

Indisputably, life is complicated. However we are increasingly ill-prepared to receive and process complex ideas and problems. The challenges facing the NHS are multifaceted, intricate and blown up to a national scale. The campaign to raise awareness of the damage being down to the health service is often waylaid by an inability to crystallise our concerns into a single message that can penetrate through the spin and lies. Worse, the constant back and forth of statistics and numbers both fatigues the general public and dehumanises the subject matter.

The past few weeks have seen the NHS at a level of crisis like no other in its history. Colleagues across the country are reporting conditions no developed industrial country should ever tolerate in their hospitals.

At this point I would normally bring forth statistics illustrating this disaster: waiting times, trolley waits, operations cancelled, ambulance queues. We’ve all tried that. It’s not working.

So, for a moment, let me simply tell you a story.

You are busy back at work after the New Year, trudging through the piled paperwork eclipsing your desk, when you get a phone call.

It’s your grandmother- she doesn’t feel well. She tells you she has chest pains. Concerned you tell her to call an ambulance straight away. It takes some convincing, but she eventually agrees.

She’s a tough elderly lady, never one to complain. She hangs up the phone and duly dials the ambulance.

You wait a few minutes and then phone her back. She tells you she called and they are on their way. Relieved you tell her to take the mobile you left her, and make sure it’s switched on. You make arrangements to leave work early to get out and see her.

An hour passes. Not hearing anything you phone back on the mobile. It bounces to voicemail. Concerned, you call back the landline. Your grandmother picks up: she’s still at home, waiting. The pain is still there. Maybe a bit more than a twinge. She feels a little sick, couldn’t manage lunch at all. You start to panic a bit, trying to see if there is anyone who can get there to take her directly sooner. You are two hours away. You hang up and dial her GP, not really sure what to do. You end up on hold waiting for a receptionist who eventually tells you to call 999. You try to call 999 but they can only tell you an ambulance is on the way. You hang up and dial again, tell her you’re on your way. She tells you not to fuss but you’re already in the taxi heading to the train station.

You try her landline again before you get on the tube: it’s been nearly two hours now and still no ambulance. You tell her to call 999 again. She says okay. She sounds weak.

The tube journey is the longest and worst of your life. Every extra delay is torture.

You get to the overground station and try her mobile again. No answer. The landline rings and rings. You dial and re dial frantically. There’s no answer. It’s been nearly 3 hours since her call. Sick with worry you bundle onto the train, desperately dialling 999, the police, an old neighbour, anyone you can think will be able to get there sooner. No one can. The train sweeps into the country wrenching your soul as you will it to go faster.

You jump in a taxi at the other end, stuff a twenty into the drivers hand and tell them to get you there as fast as humanly possible. There’s no answer on any line. The taxi driver weaves through traffic and bus lanes and jumps an orange light, screeching to a halt outside your grandmother’s house, just as an ambulance pulls up. It’s been three hours 46 minutes exactly.

Frustrated and driven mad with worry you shout and scream at the crew, who look exhausted and defeated but run up to the door and knock frantically. In the end the door is kicked in by the police. But it’s too late. You find your grandmother sitting on her favourite chair, slumped, ashen, and far too still.

It’s too late.

I work in a heart attack centre. We have strict national targets for patients having acute heart attacks- 90 minutes from arrival to a life-saving procedure to open a blocked heart vessel. We do this because we know every precious minute we wait means more damage to the heart, more risk of heart failure and death. We often get in there a lot sooner- from the moment a patient arrives at the front door a whole cardiac team is waiting for them: doctor, specialist heart nurse, radiographer and specialist cardiac physiologist. While we hear the handover we ultrasound scan the heart, take electrical tracings, blood tests, give blood thinning medication and tubes for giving fluid, examine and explain the procedure and consent the patient. At a clip this whole process takes just five minutes. We then whip the patient into our procedure room, prep the instruments and special tubes we use to access the heart, sterilise the area, hook the patient up to a monitor and blood pressure cuff, give specialist medications and then insert a needle into their wrist, then a sheath then a tube which we thread all the way into the three arteries around the heart. We take x-rays to see where we are going as we inject dye. We then thread a balloon down the tube and inflate it inside the blockage. We put a stent in to keep it open and then we relax.

On good days the patient feels better, the chest pain is gone, the artery is open. A life is saved. The clock says just 50 minutes have passed. We get them a cup of tea.

We do this several times a day, every day, day and night. The system works and it works well. It just needs the resources to run it.

For Marie Norris, the 81-year old lady who died this week 3 hours 46 minutes after calling an ambulance with chest pains we were too late. For her and dozens more, the ambulance never came.

This has been the worst winter in NHS history and we aren’t even at the halfway point yet. It comes at a time when the NHS has never had less resources for its population, never been more understaffed. If the stats and figures and endless spin don’t connect with you, think of this happening to your own grandmother. To you. Is that the country you want? Is that a government you would vote for?

Think about that.

We appreciate your thanks and support, but what NHS staff really want is to be able to do our jobs, to not have to face families who’ve been let down by the system. To not have to explain their loved one died because we couldn’t do enough, because we didn’t have the time or funds or staff. Don’t give us your thoughts and prayers, give us your action, your vote, your demonstrations. Whatever it takes.

Give us, and give yourselves, a chance. A chance more than Marie had.

Juniordoctorblog.com

 

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

“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