“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

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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

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

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.