“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

Is the NHS really over? Just the facts.

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

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

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

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

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

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

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

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

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

Immigrants I hear you say? Back to some facts.

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

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

Which is a good time to mention Brexit.

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

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

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

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

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

So is it failing? These are the facts.

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

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

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

So what will change things? 

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

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

A combination of all three is probably needed.

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

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

“Dear Sir/Madam,

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

Yours faithfully,
[Your Name Here]

But that’s just my opinion. 

Juniordoctorblog.com

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This rather excellent video series does this perfectly. 

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