Dear (brand new) Doctor…

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

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

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

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

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

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

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

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

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

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

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

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

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

13. Take all your leave. Go on holiday. 

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

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

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

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

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

19. Try your best, always.

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

It is genuinely the most wonderful job.

Good luck. You will be brilliant.
Juniordoctorblog.com

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As an NHS doctor, I like Facts. Vote Remain.

I’ve just voted. I voted for the UK to remain in Europe.

Why? Well, here’s been a lot of partisan opinions and dog whistling on both sides of the debate- the level of discourse has been a lot like a mud wrestling much- both sides have smeared each other in so much muck that you can’t really tell them apart, and you stop caring.

That isn’t surprising. We have a government right now built on the principle public relations is more important than policy, that what you say and how you appear saying it is far more important than what you do. Sentiment over substance. Both sides of the Tory schism have led the same way, into farce. The whole thing has descended into an Eton schoolyard spat, with Nigel Farage the slightly odd kid no one plays with suddenly joining in, shouting “get him Boris” and other, more racist, things that make everyone uncomfortable.

So I’ve ignored it completely; maybe you have too. Instead I turned to social media, and through my own research made a decision to Remain, based on facts and figures and nothing else.

What’s my conflict of interest? Full disclosure; I am the son of a non-EU immigrant (who is voting Leave FYI), I was state educated and  trained and am a junior doctor in the state run NHS. I pay my taxes, vote left of centre, and have a cat from Latvia. As a junior doctor no one despises Cameron, Osbourne and Hunt more for what they are doing to the NHS.

So why on earth would I side with them?

As a doctor I like facts. Cold, hard, rigourous facts. I don’t like subjectivity, vagueness or b******t. I also like human beings. I don’t like discrimination, inequality or suffering.

So here are some myths and some corresponding facts that changed my mind. Maybe they will change yours.

Here are some great sources – read them for yourself.

www.fullfact.org
http://blogs.lse.ac.uk/brexitvote/2016/05/27/dear-friends-this-is-why-i-will-vote-remain-in-the-referendum/

1) Europe is undemocratic and run by faceless bureaucrats

2) Europe costs £350 million a week

  • No. This is the gross payment to Europe, but we rebate nearly half that every year- to farms and universities. So the ‘cost’ is variable, but much less – from £168million/week to £250million/week.
  • £250 million sounds like a lot/ week- but it works out about £4/person per week, or £16/person per month.
  • For £16/month we get easy access to a market of 500million people, which means many small businesses in the UK can sell to the EU as easily as to customers at home. This is a very good thing. We send ~45% of our exports to the EU. 
  • Renegotiating all the deals would be possible but: we would have p****d off Europe, we will have pound less strong against the Euro, and we would still have to allow free movement of labour.

3) We could spend that money better on health, like the NHS

  • This is wrong, but I welcome the support.
  • The NHS is drowning with Tory underfunding- but it’s the fault of our government, not the EU or immigration.
  • In 2008 illegal and fraudulent banking practices crashed the world economy.* As a consequence our Tory government decided that the way to repair the economy was to cut public services, and they took £20 billion out of the NHS in assets, and froze the budget, despite rising demand. They plan to take another £20 billion by 2020 (including their proposed ‘extra’ £10 billion), and create the least relatively funded decade for the NHS in it’s historyThe same banking practices have already started to return by the way, although what this means isn’t certain.
  • The economy will recede again if we leave the EU – I don’t really see how it can’t. Economists worldwide agree : but ignore that fact for the moment. A market we export 40% of our goods into, have extensive trade links and agreements from selling into, and have been a part of for 40 years just disappears from our economy overnight. Yes, perhaps we can recover – maybe we can trade more with Brazil, and China, and the US, maybe we can set up the same agreements again with the EU. In the meantime, which will be years, not months, Britain could lose as much as 10% of GDP – that’s around £180 billion, or 1.5 x the budget of the NHS.
  • During the last period of austerity, worldwide it is estimated 250,000 cancer deaths occurred that otherwise wouldn’t have if the financial crash hadn’t occurred. Let me reiterate that – 1/4 million people DIED, because of financial fraud, in health systems dependent on employment for health insurance. This didn’t happen in the NHS, because of it’s public nature. But if there are further cuts to public spending, further austerity, the NHS will collapse. It might anyway. Money in healthcare means lives- don’t underestimate austerity as merely an exercise in ‘saving pennies’. It saves money from the most vulnerable in our society, and some don’t survive. It’s a crime too big to see.

4) We have to stop immigration and take control of our borders

  • 330,000 people came to this country last year. Half came from the EU, half came from non-EU
  • We already ‘control our borders’- we have full control over non-EU immigration, and all EU migrants have to present ID and passports to enter the country.
  • The arguments over immigration are flawed – read this
  • a) Essentially, leaving the EU won’t alter immigration from non-EU, which may increase
  • b) immigrants contribute more to the economy than they take out: they help us survive periods of austerity and economic downturn, like right now
  • c) 1.2 million British people live in the EU, and around 3 million European citizens live in the UK. If we deported everyone, and all the Brits returned, our population would fall, but we would have replaced 2 million working people with mostly retirees, who will draw a pension and use extensive healthcare and contribute less to the economy than the working migrants they replaced. Good idea?

5) Other rambling

  • We have to bail out the Eurozone all the time. No we don’t – we opted out.
  • The EU is a capitalist wet dream designed to oppress working people. Maybe – but look at the government we have now. (see next point)
  • We must leave the EU to escape the threat of the Transatlantic Trade and Investment Partnership (TTIP). This clandestine trade agreement between the EU and the US has been negotiated for the past five years in total secrecy – public, press and even politicians involved aren’t allowed to look at any materials. The whole thing was recently leaked – and has many scary and ultra-neoliberal proposals for companies to essentially sue governments on issues that affect it’s profits – like health and safety regulation, or state-provided healthcare. The government recently backed down and exempted the NHS from TTIP – but we haven’t seen the detail yet. To be honest I was planning on voting Leave if I thought we would escape TTIP legislation – but remember who our government is. Cameron basically invented TTIP and would sign up to it ‘in a second’. If we leave Europe we will be left with an even more far-right, ultra capitalistic government, and TTIP would just be imposed under a different name.

I may not have convinced you – but that doesn’t matter. Politics in the digital age is changing, it’s up to us to take the responsibility for how it changes. Will it become a divisive society of online echo chambers, neither listening to each other except to engage in Twitter trolling? Or will we grow up, critically seek out and appraise the facts for ourselves, escape the influence of newspapers trying to sell us sensationalist politicised rubbish, and see the world how it really is.

Remember people literally died for your right to vote. Whatever you do today, go and VOTE.

#voteremain

juniordoctorblog.com

*How? Well, watch The Big Short, but essentially banks were selling mortgages to people who couldn’t afford to repay them, and then selling those debts bundled together to other banks, who then bet on those bundles to never fail, which they obviously, spectacularly did. Imagine your friend set fire to a bit of paper, and said to you “Here, buy this bit of paper, and keep it with your other bits of paper.” Which obviously started a bigger fire, and then you said to another friend “Hey, buy this fire I just started and keep it in your house.” And then someone came along and said to HIS friend : “I bet you £1 billion that house doesn’t burn down.” Sound stupid? This is actually exactly what happened.

Do no harm does not mean do nothing

It is a common misconception that the only principle of being a doctor is ‘Do No Harm’.
The four pillars of medical ethics, beat into us at every exam and interview, are thus;

“Beneficence, justice, autonomy and non-maleficence.”

Let me explain. Beneficence simply means ‘do the best for your patient’, or more simply ‘always act in the interests of your patient’.

Autonomy means ‘respect the individuals right to make their own decisions’, and this often comes into conflict with the first pillar. The best medicine for my patient might not be one they want, or their decisions might bring them to ill health e.g smoking, but that’s their right. Some patients may not have full autonomy- advanced dementia, confusion, even being drunk. Then we act in the best interests of the patient, and do what we can.

Justice means different things to different people, but essentially is ‘treat all patients fairly and equal’, but each decision must be right for the individual patient, and respect their wishes.

Finally, non-maleficence is the infamous ‘do no harm’, but already you see the complexity. ‘Do no harm’ does not mean do nothing.

Take for example an operation to replace a broken hip. Have you ever seen it? A vital, life-saving intervention for an older person who breaks their femur (the long leg bone that ends at the hip)- it starts with a long slash across the thigh, followed by wrenching and cutting through the thick muscles to the bone itself. The head is sawn away and ripped out, the cavity ground down and shaped with power tools, a metal head chiselled and rammed in, then hammered into the existing bone. Blood flies out, cement pours in. It’s one of the most brutal things I’ve ever seen done to a human being. It certainly would constitute ‘harm’, but it serves a higher purpose- the beneficence of the patient, ie a new hip, restored mobility, and a better chance of longer life. The same could be said of nearly everything medicine does- from the needle puncture for a blood test to the toxic side effects, and indeed intended effects, of chemotherapy for cancer. To simply say ‘do no harm’ means ‘take no action’ neglects the fundamental balance of risk and benefit that underlies all medicine.

Every decision therefore is usually a conflicting mix of all of the four pillars of medical ethics, and we must synthesise every part of the law and of our own conscience to act in the best interests of the patient, fairly, safely and in line with their own wishes.

Now apply this view to the next junior doctors full strike, with emergency care juniors walking out as well.

We’ve heard plenty about the ‘do no harm’ argument – the government has lined up everyone on the payroll to give their two cents in the press. Darzi, Stephenson, Keogh, Davies. Some retired guy that resigned as chief medical officer 15 years ago.

But does it actually add up?

Let’s look at the situation on the ground. There are around 44,000 consultants in NHS hospitals, 54,000 juniors Doctors and 10,000 non training and dental staff. On any given emergency day, such as the Royal Wedding, the number of junior doctors that cover emergencies only is around 10-30% of the workforce. So in a full walk out, assuming everyone does walk out, you would need about 5000-18,000 doctors to replace them to provide emergency care. You have 54,000 non-junior doctors, consultants and other non-training doctors, on payroll, who also happen to be the most experienced doctors in the hospital. That’s without preparation. Hospitals are taking proper measures to ensure safety, led by our consultants and managerial colleagues. In fact, with the active movement of additional blood taking and clinical support staff to wards, the deployment of several consultants per striking junior, and proper bed management, some hospitals might even be the safest they have ever been. So the proposition of significant ‘harm’ is logically unlikely.
What about autonomy? The government spin machine would like you to believe we have none, we are ‘misled’ by our union, and we do not have the ability to make decisions ourselves. This movement has been led by the grassroots from the beginning- the hashtag #iminworkjeremy trended nationally in July 2015, from everyday doctors in response to the first shots from government over this contract in the press, not the BMA. Since then it has been the grassroots at the forefront, driving the BMA. Not the other way around. It is our jobs to take large volumes of information, synthesise that and make a complex decision, and then take responsibility for that judgement. To say we act without understanding is ludicrous.

What about beneficence? Much of the public don’t understand this issue, and for that we apologise. It’s about making a workforce cheaper, removing safeguards that cost hospitals money, and stretching lucrative elective weekday work into the weekend. It is, as it always has been, about money for the government, at the cost of safety. We recognise that, and we recognise that this contract will create dangerous conditions for patients, crippling retention and recruitment at a time when the NHS is already on the brink. An A&E in Lancashire closed last week due to lack of staff- we have a long term duty to patients to make sure that doctors have safe working hours and staffing levels.

Lastly- justice. I take this pillar of medical ethics to mean that every member of society should have the same healthcare, should be treated fairly based on need alone. The NHS is one of the most just and equitable healthcare systems in the world, and it is being summarily destroyed. We cannot stand by and watch this happen.

We are trying all we can to avert the next strike- we don’t want it, but it is the only treatment option we have left.

We want to talk- for the past six days doctors have been camped outside the DoH waiting for Jeremy Hunt to open his door and begin negotiations again.

In the fight for justice and beneficence Justice For Health are taking Mr Hunt to court today, issuing proceedings officially at 4pm. Their aim is to have the High Court review the government’s actions on the contract and the NHS and decide if this is safe and rational. A win in the court could avert this whole mess, a step in a new direction to save the NHS.

But they can’t do it without your help- Jeremy Hunt is trying to bully these crowd funded doctors with threats of huge costs, demanding £33,000 up front to even get the case to a judge. He is trying to use the deep pockets of the government to put down a safe, effective and reasonable intervention against a dangerous contract.
Will you help us?

http://www.crowdjustice.co.uk/case/NHS
Do no harm does not mean do nothing. If you want justice, for the long term benefit of all of us, do this.
Juniordoctorblog.com

How to solve the health crisis. Leave us alone.

Dear Messrs Cameron, Osbourne and Hunt,

You may have noticed the NHS is doing pretty badly lately; funding is at a record low, waiting times are at a record high, and morale across the service is at rock bottom.

You all made some silly promises about money- that’s okay, we all say things we don’t mean sometimes. You perhaps got a little confused and said that you were committing “half a trillion” pounds to the NHS over this parliament- which is simply the current flat yearly budget (~£100 billion) x 5 years. You said this was ‘the most amount of money ever given to the NHS’, but you might remember every successive government since 1948 could have said the same- it’s called health inflation.

You may have forgotten about that when you said you were ‘committing 10 billion‘ pounds ‘extra’ to the NHS, to fund the NHS ‘own’ plan. Except it wasn’t the NHS own plan– it was yours, and it’s not nearly enough even to keep the lights on.

Everyone’s a critic eh? It’s not nice when people say you’ve done a bad job, so I can fully appreciate why you asked hospital accountants to hide the debts under their carpets, and told hospital managers to pay for less nurses and doctors last year. I can feel your annoyance when hospitals decided that wasn’t safe, and had to hire lots more agency staff to fill the gaps. You said some silly things blaming this on agency fees, but that’s okay, 80% of the cost of this was the gaps themselves, and you won’t make that mistake again next time will you? Will you?!

You’ve said some funny things about the health service. You’ve said you want it to be the ‘safest health care system in the world‘, but I think you also want it to be the cheapest in the industrialized world? I picked up a few bits for you to read- might help. This one shows increased funding improved outcomes in healthcare. This one shows big reorganizations in healthcare don’t work at all.

You’ve said some things which, I think, aren’t true. I do hope I’m wrong. You said you were committed to keeping the NHS public – but Virgin just bought huge swathes of services, and private company contracts increased 500% this year. You have neglected to mention this, but that’s okay – government is busy work, and not everything can be in every speech. Some people might not mind NHS privatisation, but I do think you should let them know.

You’ve handled the junior doctor contract rather badly. I don’t think it’s unfair to say so. 98% of ballotted doctors voting for strike action, the first doctors strike since 1970, the first ever emergency walk out in NHS history, record levels of dispersal, record low morale. Can I make some suggestions? Have you thought about just leaving them alone?

Since 2006 they have had a £6000 one off pay cut, then a further cumulative 25% pay loss while working in the busiest and least funded decade in NHS history. But no one really complained, bar a half-hearted effort in 2012. I don’t think this is about money, but understand the context.

Doctors conditions are already poor and retention is already a problem. Record levels of doctors leave training after two years, vacancies and rota gaps have increased 60% in two years, and 1/3 GP training posts and  50% of year 3/4 A&E registrars resigning.

So what’s the hurry? Do correct me if I’m wrong, but if contract changes are cost neutral, but could threaten recruitment and retention of staff at a time when the NHS is under incredible pressure, and doctors say is categorically less safe then current conditions, one has to ask, why bother? Why not talk for another year, rather than strikes and strikes, and resignations. Not to mention the reversal of all equality workplace gains in the last decade. Mr Hunt wanted ‘certainty’ in the health service- but I cannot imagine a more uncertain time.

Why not just leave us alone? It’s not too wild an idea. You might say the BMA asked for contract negotiations and therefore the contract must change. This is like inviting your friend for tea, punching them in the face repeatedly and then wondering why they wanted to leave. You can’t force them to keep having tea at your house, and if tea isn’t essential, then why would you?

It might hurt your feelings a little bit, but that’s okay. We all have little tiffs, we all make mistakes. No need to be too proud about it. After all, why would you want to wreck a whole health service just to save face?

It must be a tricky job, being in charge of everything. Why don’t we just sit and talk for a bit, about how we might all make the NHS better?

Unless of course that’s not what you want at all. Unless you have decided that with four years of government, a weak opposition, and deep pockets controlling >50% media and the BBC, you might decide to ram through as much toxic and undemocratic policy as you possibly can. Kamikaze politics, with a hope some strong PR spin at the end will still save the next election? So why not ram through massive NHS-reorganisation and sell off, privatise the schools and the land registry, cut disability benefits and cut corporate tax, cut funding to the opposing party and turn the BBC into state-run television. Why not in fact trample the entire fabric of democracy, safe in the knowledge that the public are too apathetic to offer any significant opposition?

You are leaving them few choices Messrs Cameron, Osbourne and Hunt. Strike or resign. Perhaps it’s #timetolisten? Or better yet, just leave them alone.
Juniordoctorblog.com

Diary of a Junior Doctor 2017

August 1st
Whew. Just got my new contract! Very exciting. I’ve heard good things from government; safer, better paid, more training opportunities. Just coming in to registrar training after a year in research so excited to be back in the hospital. Obviously all this ‘ pay protection ‘ doesn’t apply to me, but never mind! They’ve given me a ‘training agreement’ to sign, allows them to roster teaching on evenings & weekends apparently, sounds great! Signed and sent.
First day tomorrow.

August 2nd
Started today- got given my ‘work schedule‘. I thought I was supposed to go through it with my educational supervisor but they haven’t assigned me one yet. Doesn’t look like rotas I remember. Here is my first week:

Wednesday– Long day 8-21.00
Thursday– Normal day 9-17.00, On-call from home to 0800am
Friday– Night 10pm-0800am
Saturday– OFF
Sunday – Night 8pm – 0800am
Monday– OFF
Tuesday– Long day 8.00- 21.00
Wednesday– Long day 8.00-21.00

Anyway, let’s see how it goes! Had my wife Jane look at it, she’s on maternity leave from surgical training at the moment with our 11 month old, and she wondered how it would work.

August 3rd

Whew! Tough first day. The hospital hasn’t filled the other registrar post yet, so I’m on my work schedule alone. Had both bleeps today, very busy, back and forth to A&E, plus did both ward rounds. Missed teaching and had to leave the training list early to see sick patients on the ward. Handover was a bit odd- one registrar was starting for the night at 8pm, and the other was working 2pm till 10pm. Not sure who was responsible for what. Quite confusing, team members turning up at different times, ended up staying till midnight trying to make sure everyone knew about the patients and plans were in place. Got home at 0100am. Jane not pleased. Rocky start.

August 4th

Had a read of the contract today- apparently I need to be reporting long shifts like last night, and should get paid for work done. Phoned an HR lady, a Ms Massey, who said as work wasn’t ‘approved’ they don’t count it. I asked her who it should be ‘approved’ by and she didn’t know. She told me to send an ‘exception report‘ to my supervisor. Tried again with my educational supervisor- apparently she’s on annual leave for the next week so will speak to her on her return. Anyway, will get some pre-bedtime time with Jack tonight, finishing at 5.00. Will have the on call phone but the trust estimate that should get five hours sleep and work maximum 25% time apparently. Sounds reasonable.

August 5th

Oh my god. Last night was horrendous- called back in to work just as I walked in the door, didn’t manage to stop working till handover, a 24 hour shift! This can’t be safe. I hope all the on calls aren’t this bad. Exhausted. Note to self: try and find this Guardian of safe working I’ve heard about. Got home just in time to take Jack to play group for an hour. He was chuffed to see his dad and mum in the same place for once. Had to go straight to bed when we got home- back to night shift tonight.


August 6th

Eurgh. Saturday. I think. Woke up at 2pm after another busy night shift. No one to hand over to in the morning- had to stay till 10.00 till the next shift person arrived. Apparently a gap in someone’s ‘work schedule’. So I’ve worked 10 hours on a day it says ‘OFF’ on my rota. This is chaos. On another night shift tomorrow. Must get some sort of work review– already! Don’t want to rock the departmental boat but this can’t be safe for anyone.

August 8th

Monday morning. Tried to stay in the hospital after another night shift and find out about supervisors and guardians. No joy with the supervisor- the covering consultant has too much to do with their own trainees they can’t do a review with me. Found out the name of the Guardian- a Mr Angel. Called his office- secretary said he had no appointments till October now, and work reviews are a six week process, and I need to submit in writing. I asked why and the secretary was a bit snappy with me- “Mr Angel is working very hard but covers three hospitals so what do you expect?”. I asked around- the BMA can’t do hours monitoring anymore. Maybe I’ll try them anyway. Don’t know what else to do. Long day tomorrow.

Aug 31st

Wow. Got my payslip today- can’t really work it out but I’m earning less than my 1A banded job two years ago. There’s more coming out for pensions now, I don’t qualify for Saturday uplift because Friday night shifts start on Friday, and the on-call work pay is estimated in advance, so it’s about £2.80 an hour. Driving back and forth at night is becoming dangerous, so I asked for accommodation to be on site overnight- apparently this has to be deducted from my pay, so I now owe the hospital money for every on call shift I work. What the f**k.

My wife’s off mat pay now so we are a bit stuck for the mortgage. I’ll probably have to do extra locum work, but I don’t know where it will fit in these rotas.

Sept 5th

Exhausted- we’ve had two resignations in my department, one first year and the other training registrar. No ones replaced them yet. Got called in to cover a shift this Saturday – Ms Massey told me it was expected for us to cover, and didn’t qualify as a locum. She gave me a day in lieu, but can’t tell me when I can take it. Missed Jacks birthday. Pretty gutted. Sent ten ‘exception reports’ in the last few weeks and no response. Where do they all go?

Sept 6th

Got hold of my educational supervisor- she seems nice enough, agreed the rota is looking dangerous but has already sent exception reports and work reviews off and awaiting replies. She doesn’t know who to escalate to either. She tried to make ‘pay amendments’ already but HR won’t accept them. The medical director is trying the Guardian but Mr Angel has just gone off sick with stress, and there’s no replacement as yet. Off the record everyone’s quite unhappy. Jane is looking at going back to work but it isn’t looking like with childcare we will be able to manage both of us, and it seems if we went part time we’d only get ‘allocated leave‘ so no chance of ever arranging time together and if we went part time we’d get paid less per hour than full time. That can’t be right? For the same work?

Sept 14th

This is getting dangerous, I’ve tried to raise it with my on call consultant– a locum this week, no clue what I’m talking about. No one is in charge of our hours and every week the rota is filled with gaps and odd hours. Our patients don’t know who is looking after them at any given time, we spend whole nights working flat out without rest, with no one to report to. People are dropping like flies now- I have had two locums on every shift for the last week.

In the meantime my work review is now ‘closed‘, as ‘rostered’ hours are within contract. I can appeal if I want. I tried to get some leave but my ‘allocated’ leave was overruled due to lack of staff, and I can only take leave on ‘normal’ days which is usually once a week. We cancelled our holiday plans. I missed Jack’s birthday and haven’t been at home with the family, awake, for a whole weekend for six weeks. It’s getting tough with Jane.

Oct 1st

I managed to get through to the new Guardian- this one is one of the board of directors at my hospital. He’s rejected my appeal for a work review, citing ‘exceptional pressure’ on the hospital. He gave me an appointment to resubmit in 6 weeks- I pointed out I will have moved to my next job by then. He didn’t care. I snapped. I can’t do this anymore.

Oct 10th

I spoke to the BMA today- they don’t have any powers beyond issuing reprimanding letters, which they already have. I’m burnt out, I feel jet lagged every day, I don’t even care about my patients any more. I know this isn’t safe- so I have handed in my notice. Jane has got a job in surgery in Vancouver, so we are out. Will it help the patients? No- but staying isn’t helping either. If they want to collapse the system, then it’s too late to do anything about.
If only we’d stopped this when we had the chance.
Juniordoctorblog.com

Omnishambles? It’s far worse than that.

It’s been a long week for the NHS in politics. The week opened with the announcement of further doctors strikes, three 48-hour emergency care only periods in two months, plus the launch of a legal enquiry into the imposition of the contract.

Jeremy Hunt’s and David Cameron’s argument  goes like this;
“Studies show we have excess death on the weekend because we do not staff our hospitals properly. We need to create a ‘7-day’ NHS to fix that, and this junior doctor contract is needed to do so. We are putting £10 billion into the NHS to achieve this.’

The government has spun a tight narrative over the last six months- but this week it began to unravel.

Firstly the most quoted ‘study’ it emerged last week was shown to the DoH and Jeremy Hunt before it was verified and published; a serious misdemeanour for both ministers and ethical research. David Cameron missed the point at PMQs, mixing up two studies from different years as ‘estimates’, and continuing to misrepresent both. Interestingly he claimed that the Freemantle study arose ‘based on a question asked by the Health Secretary of Sir Bruce Keogh‘. Did the Prime Minister just intimate the government commissioned its own research?

Staffing hospitals is a major issue it would seem- but not at the weekend, throughout the week. During a DoH public accounts committee meeting it became apparent that due to overzealous ‘efficiency’ targets trusts were told to reduce staffing. When this became unsafe they hired agency staff to fill the rotas leading to the £2.8 billion deficit this year
NHS chief executives are also concerned that trusts prioritise ‘quality’ over ‘costs’. In healthcare I think most people would do the same.

On top of this the BBC reported a 60% rise in vacant posts for doctors and a 50% rise for nurses in two years. With so little staff do the department of health think it safe to stretch the NHS to a ‘7-day’ service?
Well it would seem they haven’t thought about it at all. In the same PAC meeting it emerged the Dept of Health have no formal strategy for ‘7-day’ services; they don’t know how much it costs, they don’t know how contract changes will achieve it and they don’t know the impact it will have. That sounds very dry so let me characterise that.
You go to see your doctor feeling tired. She says “you have cancer and we must start treatment straight away.” You are rightly upset.
“How do you know?” You ask.
“Well there are significant ‘data gaps‘ in the judgement, it’s not just scientific fact you know, and we need ‘certainty‘ going forward so, yeah. But we must start treatment straight away- I don’t know how much it costs, what the treatment is, and it’s probably very damaging. To be honest, I have no idea. I’m ‘flying blind’ on this one, but I’m going to impose this treatment anyway, because I’ll get sacked if I don’t’.

So where did this contract come from, if the DoH hasn’t actually done the work that demonstrates its necessity?
In a great article that looks into its origins Steve Topple reveals a group of hospitals proposed taking advantage of a (disappearing) excess of doctors in training to drive down pay and conditions. The originators of that work now hold high level positions in the NHS administration.

Lastly, the money. The NHS needs £30 billion to maintain current standards by 2020. The government chose to make £20 billion of cuts to services and put in the least funding rise in the history of the NHS- 0.9%/year. This is the £10 billion in every Tory quote- that was only ever going to (try to) keep the lights on. Cameron thinks it will pay for a 7-day NHS, despite no one knowing what that will cost, and Hunt is paying for a ‘paperless’ NHS, 7-day services and who knows what else. The £20 billion in ‘cuts’ is already creating huge deficits in care- the £2.8 billion ‘deficit’ this year in trusts is a direct consequence of this political decision. Despite the governments insistence- the NHS is dangerously underfunded.

In a speech to the King’s Fund, Professor Don Berwick, US healthcare expert and former government patient safety advisor, agreed;  “I know no nation that is seeking to provide healthcare at the level that western democracies can at 8% of GDP, let alone 7 or 6.7. That may be impossible.”

Meanwhile the NHS crumbles- in a stage managed fashion as private companies come to collect. This is #cams7dayscam, and far from being an omnishambles it is a controlled demolition.

We need to make it clear to sitting MPs that this is a disaster that we will hold them personally accountable for, an issue that will make or break their political careers for years to come.

The NHS is nearly done- record waiting times, record deficits, record staffing gaps, record low morale. It needs more money and better leaders. We are desperate to get this message out: if you want the NHS to survive you must fight for it, because David Cameron and this government are going to destroy it if you don’t.

Join us on the picket lines March 9th and 10th.

Juniordoctorblog.com

Imposition? This was never just about a contract.

Jeremy Hunt has gone nuclear and in a statement on 11th February announced forced contract imposition.

You may have heard the story of this dispute as told by Jeremy Hunt- it goes like this.
‘People have less good care at weekends in hospital, because junior doctors are not available. We should have a seven day NHS. We need more junior doctors on weekends but we can’t pay for this, so we will need to make it cheaper. We have to impose a contract to do this.’

This is mostly rubbish. juniordoctorblog explains the dispute so far.


 

Why aren’t there enough junior doctors at the weekend?
I personally work 1 in 4 weekends and nights already- every single patient admitted, 24/7, is seen immediately by a junior doctor – that might be the senior A&E registrar, or the general surgical or medical registrar. We have a ‘banding’ supplement that acts as a financial penalty to stop trusts rostering unsafe hours – trusts that breach this get fined, and therefore invest properly in hiring sufficient doctors to cover the rota. To suggest we don’t have junior doctors on the weekend is ludicrous.

Could there be more doctors on the weekend? Yes of course- but we don’t have many doctors to begin with; there are 2.8 doctors for every 1000 people in the UK- some of the lowest in Europe. There are also huge gaps where doctors should be already throughout the week- in A&E for example 1/8 training positions are empty, and GP posts are 1/3 unfilled. Applications for many training jobs continue to drop, and doctors increasingly migrate. This contract won’t create any more junior doctors.

So where will ‘more doctors on the weekend’ come from if there won’t actually be any more physical doctors?
Well, you could train more- but applications to medical school are dropping year on year, and this would take 7-10 years. You could hire more from abroad- but there are no plans to do this. The only place remaining is moving doctors from the week- leaving new gaps Monday to Friday, when activity and admissions are busiest. Due to imposition many doctors will also resign– meaning we have less doctors than we physically started with.

This doesn’t seem like a good idea.

Why is care less good at the weekend?
We are not sure it is. There been a few big studies that suggest patients admitted at weekends have a slightly higher risk of dying than those admitted during the week. Why this is nobody has researched. It might be the care in hospitals- but the same studies show patients already in hospital are less likely to die at weekends. It might have nothing to do with hospitals- patients are generally more unwell and more emergencies come in at the weekend- this could reflect less GP cover, less hospice access or longer delays coming in by patients- the truth is no one knows.

Is it worth finding out?
Absolutely- mostly because of the very large cost- both financially and in staff morale- in making huge changes without knowing if this would actually make care better and not worse. But this hasn’t been done. A summary of all the research done so far, if you are interested, is here.

What is a seven day NHS?
That’s a good question- no one really seems to know. David Cameron thinks it’s about having GPs 24/7. Jeremy Hunt says sometimes it’s about fixing the ‘weekend effect’ which is nearly exclusively emergency care, while other times it’s about routine care in hospitals. NHS management says it’s about emergency care and sets out 10 clinical standards – most of which are already nearly met, and none of which include junior doctors. So what exactly this means or why this is relevant to junior doctors- no one seems to know.

How is this going to be paid for?
Short answer- it isn’t. Long answer- the government announced an ‘extra’ £10 billion for the NHS in the autumn statement- and apparently this will pay for the 7-day NHS – although how it will pay for a service that no one knows exactly what it is I’m not sure. However- NHS trusts are running out of money trying to fund the services they already have- £2 billion in debt this year already. The NHS asked for £10 billion, which includes the £3 billion already announced, by 2020 just to keep the lights on- not to fund extended services. So – it isn’t being paid for.

Why can’t the government pay for more doctors at the weekend?
Well- we don’t spend a lot of money on healthcare. Currently 8.5% GDP– the lowest in the G7 amongst the lowest in Europe. By 2020 we will be paying 6.7% – amongst the lowest in the industrial world- nearly half what Germany spend, a third of what the U.S. Spends. There is therefore money available for the NHS but it is not being spent, and less and less is spent in relative terms every year. The government often say that a ‘seven-day’ NHS was a manifesto commitment, which is why it is so strange not to fund it properly. It’s not that they can’t pay for it, but they don’t want to.

Why did the government impose the contract?
They claim it was to end ‘uncertainty’ for August 2016- but there really is no reason the contract must be implemented by then. Talks have been going on for three years- contracts are reissued every August. It’s entirely political- to look ‘muscular’, to keep ‘political capital’. Nearly no one supports imposition other than NHS bureaucrats- the Royal Colleges, NHS Trust Executives and the entire medical workforce are all opposed.

So to summarise the government want to take away financial safeguards and cut pay at weekends to fix a problem we are not sure is either fixable or genuinely a problem but we do know will cost a lot of money that isn’t being invested and won’t actually be fixed because we still don’t have any more doctors- probably much less now.

Which doesn’t make sense.

So why do it?
Well the contract actually has many other advantages to the government – it increases pension contributions, and reduces the doctor wage bill to hospitals. It also means lucrative routine work can be done cheaply on the weekends, and for generations to come doctors will cost less. This is the real reason the government want this contract to happen- it will make the system much more attractive to private companies.

What’s going to happen now?
After the junior doctors the same terms will go to the consultants, the GPs, the nurses and the other health professionals.

And then?
In all seriousness- the end of the NHS. A beleaguered system which has been underfunded for years, with huge gaps in many areas, is now being squeezed one too many times.
The junior doctors have been trying to tell you that the NHS is in desperate trouble – not just from this contract alone, but as the start of a succession of workforce changes.
Private companies have taken 500% more contracts in the past year, the head of the NHS is a former U.S. Healthcare company executive, the last health secretary now works for a private health company having changed the law to make it far easier for private companies to get NHS contracts, and the current health secretary wrote a book idealising the privatisation of the NHS. 

With this latest development NHS morale will be even lower, and private companies will welcome the chance to ‘improve’ pay and conditions for staff.

What can I do about it?
If you want a free at the point of service public health system, where your taxes fund an efficient and equitable health service that you never have to worry won’t be there for you or your family, then you need to read this and understand. If we do nothing, by 2020 there will be no NHS.

Write to your MP- and tell them this is the single issue you will be voting on. Don’t accept anything less than the truth- you know now what is at stake.

Educate yourself more; read more about the health service, the contracts, the challenges it faces.

Sign this petition. Join up to local save your hospital groups and support their events.

Come to the junior doctor protests- I would love to talk to you.

Keep writing, come to protests, add your voice to every gathering, every social media group, every local council meeting.

Get on a box and shout as loud as you can. This is what democracy should be. Let’s hope it’s not too late.

I am ashamed to say Nye Bevan encountered incredible resistance from doctors at the beginning of the NHS. But that’s not the generation of doctors we have today- we all grew up with the NHS, most of us were born in it, and we all want to defend it as long and as fiercely as we can.

We can’t do it without your help.

Juniordoctorblog.com

How to Sell The NHS: Appendix 1 – Dealing with Troublemakers

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Dear Dept Of Health,
I am very pleased to hear you have been following my step by step programme; “How to Sell off the NHS; A Users Guide“.
Obviously you seem to have hit a bit of a bump with the junior doctors- but always happy to troubleshoot a good privatization! Here’s a quick road map to where you’ve gone wrong and what to do to get back on track!

Mistake #1 – You didn’t smear everybody beforehand. A good smear campaign is like suntan lotion- if you don’t get it everywhere then it doesn’t work! Excellent work on attacking GPs and Consultants- but you forgot those pesky junior docs! Nice catch up efforts [1]– but surely you can come up with something better than Facebook holiday snaps?

Mistake #2 – Doctors aren’t miners. [2] Nurses aren’t miners. No one in this situation is a miner. You don’t have to dress up as Thatcher every Halloween. You’ve forgotten the first rule of dismantlement- keep it quiet.

Mistake #3-  Stop being surprised doctors don’t want to screw over other doctors. Nice try with ‘pay protection’ [3]– but you realise this just highlights exactly how much the next generation are getting cut by? Doctors tend to be doctors forever and it’s hard to avoid your junior colleague’s eye for 40 years. You’ll get a squint.

Mistake #4 – You p***d off the anaesthetists. You probably don’t know this but every doctor, at some point in their training, had to phone the anaesthetist and grovel for help. Usually when they were right up s**t creek, minus paddle. No doctor would think hacking them off is a good idea. You could’ve hated on histopathologists until the cows came home by the way. Missed a trick there.

So what to do? Well here’s an idiots guide to breaking the strike and getting those dirty no good training docs into some great cheap labour for the privatization wagon.

1) Keep on spinning – it doesn’t matter what’s true or not. Keep using selective phrases from research about weekend mortality, [4,5] and then mention junior contracts straight after. Hopefully people won’t notice they’re not linked at all. [6] Like when the newspapers put a giant picture of someone they hate on the front page next to a completely unrelated story with an offensive headline like ‘SEX OFFENDER’. Smear them for being militants [7], or trotskyists [8], or extravagant jet setters [9] or even women [10]. Eurgh. Bloody pacifist militant socialist aristocratic 50% of the population.

2) Take the opportunity to completely bury any other problems- cut the NHS bursary [11,12] (oh? You didn’t manage that), carpet the NHS reinstatement bill [13], and quietly suppress safe staffing level reports and whistle-blowing junior docs. [14,15] Keep TTIP super quiet [16]- holy Boris bikes you don’t want the public nose in that!

3) If you get challenged on statistics you’ve used don’t worry- get this phrase made up on some rubber stamps “there is clear clinical evidence of [insert whatever you are wrong about here] – and we make no apology for doing something about it”[17,18,19,20] Stamp it on every response from angry academics who actually wrote the research you have misrepresented. Don’t worry about investigative journalism- pretty rare to find any these days.

4) If you aren’t winning here – just hire a few £million worth of extra spin doctors [21]. Way more value for money than real doctors.

5). Pretend like you’re not actually responsible for this -take every opportunity to ‘slam’ your own organisation. [22,23] Make a slam book. If this isn’t demoralising enough why not leak some ‘well-placed’ sources as veiled threats on the news to get your point across. [24]

6) And whatever you do- don’t sit down with the doctors in a public place. [25] They spend their lives accruing knowledge and applying it in life saving situations – in a head to head debate you will definitely get shown up as a disingenuous moron. But flush out those handy think tanks [26] you pay so much for and get them out there as ‘balanced’ opinion holders. No one will notice their huge conflict of interest as privatisation lobbyists taking cash from big tobacco on the side. [27]

7) Money. Don’t mention it unless preceded by the phrase ‘extra’ [28] or simply total up expected underfunding as five yearly totals so they sound huge. Ignore the fact this is complete nonsense. [29,30] Pretend hospitals are like houses or supermarkets- people understand those. If you cut a hospital budget- that sounds bad, but if you tell a hospital to ‘live within their means’ [31]– well, that’s just good old fashioned common sense.

And don’t worry if you lose your job. Some very friendly chaps at a grateful private health company will greatly appreciate all that you’ve done for them while fondling the public purse. They really appreciate it. REALLY. [32]

And the best news of all? Even if you p**s off every doctor and nurse in the country they will still give you the same world class service they give every patient if you need them, any hour of any day. Phew. Idiots.

Juniordoctorblog.com

 

[1] http://www.donotlink.com/htxh
[2] http://www.theguardian.com/society/2015/nov/19/nhs-bosses-pressure-hunt-arbitration-junior-doctors
[3] http://www.nhsemployers.org/your-workforce/need-to-know/junior-doctors-contract/faq
[4] http://www.bbc.co.uk/news/health-34598335
[5] http://www.huffingtonpost.co.uk/2016/01/13/junior-doctors-jeremy-hunt-professor-nhs-stroke-deaths_n_8973206.html
[6] https://juniordoctorblog.com/2016/01/11/the-hateful-eight-an-exploration-of-the-evidence-presented-for-jeremy-hunts-weekend-effect/
[7] http://www.donotlink.com/hady
[8] http://www.donotlink.com/i20t
[9] http://www.donotlink.com/hu3o
[10] http://www.donotlink.com/hwtn
[11] http://www.bbc.co.uk/news/business-34919523
[12] http://www.bbc.co.uk/news/uk-35263402
[13] http://www.theguardian.com/society/2016/jan/26/caroline-lucas-green-party-labour-repeal-tory-nhs-reforms
[14] http://www.telegraph.co.uk/news/nhs/12110806/AandE-units-may-be-short-staffed-half-the-time-secret-guidance-says.html
[15] http://www.54000doctors.org/thecase/2-what-is-whistle-blowing-protection.html
[16] http://www.theguardian.com/business/2016/jan/26/anger-government-blocks-ttip-legal-documents-nhs-health-service
[17] http://www.theguardian.com/politics/2015/oct/15/doctors-cabinet-office-investigate-jeremy-hunt
[18] http://www.independent.co.uk/life-style/health-and-families/health-news/plan-to-put-price-tag-on-nhs-medicines-is-a-headline-grabbing-gimmick-says-journal-10444508.html
[19] http://www.mirror.co.uk/news/uk-news/jk-rowling-supports-junior-doctors-6650327
[20] http://www.mirror.co.uk/news/uk-news/furious-junior-doctors-deliver-giant-7221155
[21] http://www.independent.co.uk/news/uk/politics/labour-accuses-government-of-hiding-rising-special-advisers-bill-a6775561.html
[22] http://www.donotlink.com/i212
[23] http://www.belfasttelegraph.co.uk/news/uk/jeremy-hunt-slams-nhs-over-utterly-unacceptable-failure-to-probe-deaths-34276082.html
[24] http://www.bbc.co.uk/news/uk-politics-35298370
[25] http://medlines.org/2015/11/24/jeremy-hunt-snubs-nhs-junior-doctors-strike-debate/
[26] http://www.donotlink.com/i217
[27] http://www.tobaccotactics.org/index.php/Adam_Smith_Institute
[28] http://www.itv.com/news/update/2015-04-11/jeremy-hunt-we-can-fund-extra-money-for-nhs/
[29] http://blogs.channel4.com/factcheck/factcheck-george-osborne-generous-nhs/22104
[30] https://juniordoctorblog.com/2016/01/05/its-the-spin-that-wins/
[31] https://www.facebook.com/JeremyHuntMP/posts/992474864129700
[32] http://www.theguardian.com/politics/2015/oct/20/andrew-lansley-advise-firms-healthcare-reforms

The Hateful Eight: An Exploration of the evidence presented for Jeremy Hunt’s ‘Weekend Effect’ – UPDATED 13/1/15 with Stroke data

“We now have seven independent studies showing mortality is higher for patients admitted at weekends.”
JEREMY HUNT, ALL THE TIME.

You can view these seven (or rather eight) ‘studies’ here:

On the basis of this evidence Jeremy Hunt and the Department of Health have put forward the argument for sweeping changes to the NHS to create ‘Seven-Day’ services.

Juniordoctorblog deconstructs the Hateful Eight.


DISCLAIMER: this is written for a lay person. Further details on all the papers available on request.

1. Increased mortality associated with weekend hospital admission: a case for expanded 7 day services?  by Freemantle and Sir Bruce Keogh, published in the BMJ in 2015.

This is the most recent and most quoted paper, and where the soundbites “11,000 excess deaths” and “16% increased probability of death” come from. The study was performed by a group of researchers which included Sir Bruce Keogh, and was commissioned on his request, which makes the claim “independent” rather dubious. The study was an update of a 2012 paper (see below) and therefore 2 of the Hateful Eight are actually the same paper for different years.

This study pulled numbers from Hospital Episode Statistics, which records patient information from the discharge summaries written by junior doctors when you are discharged from hospital. If you have ever been to hospital you would know this is not always 100% accurate. The study identified the day of admission for every patient admitted to hospital in 2013/4, and then counted how many patients had died at 30 days after admission.

Overall just over 1.5 in 100 patients died in the study. They found patient deaths were LOWEST on Sunday, and HIGHEST on Wednesday, but for those ADMITTED on a Sunday or a Saturday they found a small increase in the risk of death at 30 days, an absolute increased risk of 0.07%* for admissions between Friday and Monday, compared to those admitted on a Wednesday.
The study also found 1/3 of patients died after being discharged from hospital, and the majority died after 7-8 days in hospital. For the first time the study tried to work out how sick patients were and found a higher proportion of the very sickest patients were entering the hospital on Saturday and Sunday compared to the weekdays. The authors conclude ‘to assume these excess deaths are avoidable would be rash and misleading’. At no point did this study measure staffing levels, rota cover or hospital resources, and the figure “11,000 excess deaths” is a statistical guess based on the numbers the study cranked out – they are NOT real identifiable cases.

BOTTOM LINE: Patients admitted at weekends are sicker, and they have a very tiny increased risk of death compared to the weekday admissions. “To assume this is avoidable is rash and misleading.”

2. Weekend hospitalisation and additional risk of death: an analysis of inpatient data by Freemantle/Sir Bruce Keogh published in 2012

This was the original paper as described above, by the same group from the same data using broadly the same methods. The only thing to add for this paper is it actually found patients in hospital on a Sunday were 8% less likely to die than those on a Wednesday.

BOTTOM LINE: 2 papers from the ‘Eight’ are written by Bruce Keogh of NHS England and are actually the same paper repeated.

3. The Global Comparators Project: international comparison of 30 day in-hospital mortality by day of the week by Ruiz, published in BMJ Quality and Safety 2015

The authors for this paper work for the Dr Foster Unit, sponsored by Dr Foster Intelligence: a former Department of Health co-owned patient safety monitoring company. They looked at the same data as the above from the Hospital Episode Statistics warehouse, and compared this to other countries: USA, Australia, the Netherlands and several more. This study looked at emergencies and routine surgery only for 2.8 million patients, 1.3 million of which came from the UK. For surgery, the UK had the lowest risk of death at 30 days. Emergency admissions were sicker than planned admissions. The results were similar for all countries studied, suggesting that this is an international phenomenon. UK planned surgery patients who had procedures on a Sunday, before adjustment**, were 0.7% more likely to die than those on a Monday. For emergency admissions the risk was 0.4% higher on a Sunday compared with a Monday. The effect was seen in nearly every country. Again this study performed no measurement of staffing levels on each day and the authors conclude themselves “we are not able to determine the reason for these findings.”
BOTTOM LINE: The ‘weekend effect’ is seen across the world in varying health systems.

Now is a good time to pause and discuss mortality. Imagine if you will two hospitals. Hospital A has a 90% mortality rate at 30 days – 90 in 100 people die within 30 days of admission, while at Hospital B the rate is only 2%, or only 2 in 100. Which would you rather be treated at? On the face of it, the answer would be Hospital B, because the obvious logic is: all illness should be curable, therefore I go to hospital to get better, therefore I choose the hospital where I have the greatest likelihood of getting better, ie not dying. Which makes sense: except if I told you Hospital A is a hospice, for end-of-life terminal cancer patients, and Hospital B is a community minor treatment unit for children, for scrapes and bruises and runny noses. Now this changes your perception of the figures: Hospital A has a surprisingly low mortality rate, considering everyone admitted is there to die peacefully, and Hospital B has a worringly high rate – considering no one should be dying at all. Now what if I told you Hospital C had a 1% chance of death for a procedure, and Hospital D had a 1.1% chance? Would you be bothered which hospital you went to? I wouldn’t. But if I told you that Hospital D had a 10% higher probability of death than Hospital C, you might change your mind. This illustrates the problem with superficially accepting statistics and why it’s so important to properly scrutinise the figures. Anyway, back to the papers.

4. East Midlands Clinical Senate (2014), 7 Day Services Project: Acute Collaborative Report

This is not a scientific report at all, but a consulting report from ATOS. The same ATOS that the Department for Work and Pensions recently dropped for the ‘poor quality of their work’. The report is from a group of executives from the East Midlands. It’s really dull, and not scientific at all – all of the numbers come from the other ‘studies’ here in regards to weekend and weekday working. Of 10 clinical standards for ‘seven-day’ services it found all were already being met 50-60% of the time. The biggest fail areas were ‘mental health’ and ‘transfer, discharge to social care’. Both budgets of which have been cut in the last ten years. However, here are some favourite quotes

“It is likely unsustainable and unnecessary for all trusts to provide all services 7 days a week”.

“There may be a need to drive funding for the whole system to deliver 7 day services”.

Here is a good time to remind readers the last eight years have been the worst funded decade for the NHS in its history (including the recently announced ‘extra’ £3 billion). Again no measure of staffing levels and no mention of junior doctors.

BOTTOM LINE: 7 day a week routine services require proper funding and are not necessary or sustainable in all areas. A good proportion of 7-day emergency services are already available.

5. NHS Services, 7 days a week report by NHS England/Sir Bruce Keogh

This is a policy document from NHS England and, again, Sir Bruce Keogh’s office. Also, again, not a scientific ‘study’ at all. Interestingly the focus is nearly entirely on emergency services – no mention of ‘routine’ care at all. The review notes that doctors and nurses are present on the acute medical unit 100% of the time weekday or weekend, the importance of diagnostic services being available 24/7, and lots of case studies- all of which achieved better cover without changing work conditions for staff. Interestingly in the annex it notes that many more weekend admissions are end-of-life patients compared to the weekdays- suggesting an increased need for community hospice and palliative care services.

BOTTOM LINE: Bruce Keogh and friends re-hash other research in this list- but importantly define the need for seven-day services as emergency care improvements, not routine services.

6. Academy of Medical Royal Colleges Report: 7 day consultant present care published in 2012

Again, not a unique scientific study but a review of many other studies. Produced by the Academy of Medical Royal Colleges to look into the necessity and feasibility of increasing consultant presence on the wards for emergency unscheduled patients. Again, not routine services and again, nothing about junior doctors or staffing levels.

BOTTOM LINE: Consultant presence is important for emergency admissions, not routine services.

 7. Weekend mortality for emergency admissions: a large multicentre study, BMJ Quality and Safety by Aylin published in 2010

Here is an ACTUAL scientific study, another from the Dr Foster Unit at Imperial College London (which was 50% part owned by the Dept of Health at the time of writing). This is the fourth study in this list that uses the Hospital Episode Statistics warehouse: again discharge letter information. This paper focused only on emergencies. They reached the same conclusion as the papers above, with an absolute increased risk of death at the weekend vs the weekday to be 0.12%*. They didn’t take into account how sick patients were, or their method of admission, and again no explicit measure of staffing levels were made.

BOTTOM LINE: A fourth study from the same data, showing a very small increased risk of death in weekend vs weekday emergency admissions, and no accounting for how sick patients were or staffing levels.

8. Time for training Report by Professor Sir John Temple from the Department of Health published in 2010.

Unfortunately this the original report has disappeared but in summary this was another policy document from the Dept of Health looking at the issue of training doctors under the European Working Time Directive. It’s main conclusions was that shift work is anti-social and has had an impact on training, and that consultants should be more involved in 24/7 work to support trainees.

BOTTOM LINE: Another non-study, suggesting a larger consultant presence day-to-day would help training. Nothing to do with the ‘weekend effect’.

I’d be remiss for not mentioning the latest papers in the ‘weekend effect’ argument, which haven’t quite made it onto the gov.uk website yet but are already in the briefs and interviews of Mr Hunt and the spin machine.

9. Association between day of delivery and obstetric outcomes: observational study by Palmer, published in BMJ 2015

A fifth paper looking at Hospital Episode Statistics, and the third from the Dr Foster Unit. It is remarkable actually that no single paper has tried to analyse ‘the weekend effect’ in any other way than use the same source. This group tried to identify a weekend effect on seven different measurements associated with giving birth. Overall the stillbirth rate was 0.7%, or 7 in 1000. It actually finds that the stillbirth rate is significantly lower on Monday and Tuesday, which had

‘no association with staffing’.

BOTTOM LINE: No  link between mortality and staffing, and no obvious ‘weekend effect’ (Thursday had the highest rate of perinatal mortality.)

10. Mortality of emergency general surgical patients and associations with hospital structures and processes by Ozdemir published in the British Journal of Anaesthesia in 2016

This study unsurprisingly also used the Hospital Episode Statistics database, looking at all emergency admissions undergoing surgical procedures or admitted with pancreatitis over five years. The study then cross-referenced these numbers with data about the hospitals it was collected from – e.g. staffing levels, number of beds etc. The methodology in this paper was actually quite good, and they show a very strong association with the number of doctors, nurses and beds and the association with better surgical outcomes- of course this does generally reflect the amount of money a hospital has, and how well-resourced it is overall. The weekend data shows the same bump in mortality at the weekend as all the other studies that looked at the HES data, but didn’t measure weekend vs weekday staffing levels, as many media stories wrongly reported.

BOTTOM LINE: Increasing resources improves outcomes from emergency surgery, regardless of the day of the week.

UPDATE: Following the strike announcement Jeremy Hunt began quoting ‘you are 20% more likely to die from a stroke at the weekend’. Given how stupendously dangerous delaying presentation to hospital is for a stroke I’ve updated this post to add in the following; (Full credit to Prof David Curtis and Ben White for drawing this to public attention.)

11. Mortality following Stroke, the Weekend Effect and Related Factors: Record Linkage Study published on PloSOne in June 2015 by Roberts.

This was a study that took the Welsh equivalent Hospital Episode Statistics and looked specifically at patients who were admitted to hospital for a stroke between 2004-2012 and counted how many died at 7 days, 30 days and 1 year. They found less patients were admitted on a weekend for strokes (88) and patients admitted during the week (111), and a small increase in mortality of 1.8% at 7 days between weekend and weekday admissions. There are three really important things to say about this:

  • 1) The study notes – stroke mortality fell by 3.1% every year for the 8 years of the study. This reflects the radical improvement in stroke care that has occurred over the last twenty years with the introduction of ’emergency’ stroke pathways and hyperacute stroke units. Here is a nice graph. This study doesn’t really factor in this massive improvement in overall care, and isn’t relevant to today. Also – this improvement was done without changing working conditions for staff.Stroke trends
  • 2) Stroke occurs on any day with equal frequency except mondays– where it is slightly higher. Stroke can range from transient weakness or loss of vision which resolves after 24 hours, to permanent loss of power to limbs and face and even death. The authors note that the effect ‘may be influenced by a higher stroke severity threshold for admission on weekends’. If you look at day of stroke, regardless of admission, there is NO WEEKEND EFFECT, as seen here in a study from Japan.
  • 3) Stroke is defined as ‘maximal at onset’ – it represents sudden and complete blood loss to an area of the brain. There is only one main treatment, which is to give clot-busting medication. However- this is very dangerous and the list of situations where the risk of the treatment outweighs the benefit is very long. Having worked on-call in a stroke unit and ICU previously I have only seen one patient who met the criteria. Only 15% of strokes were treated this way in 2014. 60% of patients came to hospital too late for treatment. Stroke is now treated as an emergency – the ambulance calls a stroke-centre hospital before the patient arrives, and a specalist team sees the patient as soon as they come in to the door. The limiting factor now is when the patient dials 999.
  • 4) Lastly, a recent study found the presence of a consultant or doctor had no effect on a patients survival after stroke, whatever day of the week they were admitted. However, the presence of adequate nurses had a huge impact: increasing nursing numbers from 1.5 nurses/10 beds to 3 nurses/10 beds reduced mortality by 4%. This reflects the fact that stroke patients are very vulnerable in the immediate period after the event, and it’s good nursing care, not junior doctors, that directly influence this. However – Jeremy Hunt has so far suppressed the NICE recommended safe staffing levels for nurses- and the NHS student bursary to incentivise nursing training has been cut.

BOTTOM LINE: This study took place 12 years ago, in Wales, during a time of rapid improvement in stroke care overall. It shows a reduced number of strokes admitted on the weekend – and likely increased severity of those admissions resulting in a small 1.8% bump in mortality overall. Jeremy Hunt’s scaremongering has previously led patients to delay coming to hospital – in this particular case this could lead to devastating loss of function and even life. Time is the single biggest factor in survival in stroke, and has nothing to do with  weekend doctor staffing or junior contracts.

Now time to look at things differently. You hear a lot about the studies showing a ‘weekend effect’. But did you know there are many studies that show no effect? The fact that you don’t is an example of something called publication bias – the government only wishes you to think the ‘body’ of evidence all points one way. It doesn’t.

Here are some studies that show NO WEEKEND EFFECT.

Weekend mortality in paediatric patients in Scotland – published by the Royal College of Paediatrics, Turner 2015. [1]
Byun 2012 (small study compared to the others) [2]
Kazley 2010 (US study) [3]
Kevin 2010  (Canada) [4]
Myers 2009 (USA) [5]

Overall: 

  • Of the ‘Hateful Eight’ studies only four represent actual research
  • Two are the same paper and co-authored by Sir Bruce Keogh,
  • The other two are from Dr Foster, formerly owned by the Dept of Health.
  • All of the studies come from a single source of data.
  • None of them show any link to staffing levels, and none of them show any link to junior doctors working patterns.
  • Much research exists disputing the weekend effect
  • Research shows that increasing resources improves outcomes. Which is obvious.

And here is the pièce de résistance. When there is a finite amount of money the logical management of resource is to put money where it will do the most good. The National Institute for Health and Care Excellence, NICE, have a recommended money spent vs benefit formula for approving treatments. The cut off is currently about £20,000 to buy a year of quality life. This is how all new medications are decided if they are value for money or not.

Meacock in 2015 sat down and worked out the cost of a ‘seven day NHS’ and then tried to work out if NICE would approve if it were a medicine. Needless to say the money spent (estimated for emergency services to be £1-1.4 billion) is 2x-3x as much as the ‘recommended’ cut off.

BOTTOM LINE: This isn’t even good value for money.

Finally – some context. Every year in the UK 25,000 people will die of a blood clot to the lungs, 60,000 people will die of a heart attack, 30,000 people will die from chronic lung diseases, mostly smoking related. Improving research and treatment pathways for any of those conditions would save more lives than this endless politically driven ‘seven day’ debacle. I dread to think how much money has already been spent on the ‘seven-day’ services problem – but if it is real, it is a tiny relative problem and a problem no country anywhere has been able to solve.


All doctors would want to have the entire gamut of services on hand every day of the week – but the first lesson of practicing medicine is learning to prioritise. So far, the ‘studies’, simply don’t add anything useful to the debate – we need to know where and how to spend our money, whether that’s in the community, in social care, in improving hospice care, or in expanding emergency departments or increasing perioperative care. The list goes on. It’s not clear there is a truly avoidable ‘weekend effect’, but more importantly it’s not clear if it’s worth the vast amounts of money, damaging publicity, time and general consternation being spent on it.

This is a classic situation of political meddling in the NHS creating harm. We have a government and media who prefer soundbites to sound decision-making and spin doctors to actual doctors. THIS is the true threat to the safety of patients.

juniordoctorblog.com

 

How To Sell Off The NHS: A Users Guide

So you want to sell off the NHS? A 65-year old behemoth, part of a raft of reforms that radically improved the quality of life of working people for nearly a century? It won’t be easy, but with this handy step by step guide you too can privatise your health service.

Step One
Know your enemy. In 2010 a Kings Fund poll put NHS satisfaction at above 70% [1]- the highest ever recorded approval rating. The United Kingdom has low child mortality outcomes globally; 5 per 1000 live births, (compared with world number 1 – Iceland at 2 per 1000 and the U.S. At 8 per 1000), long average life expectancy (male); 79 (compared with world number 1 Iceland at 82 and the U.S. at 76) and for maternal mortality the UK has an estimated 8 deaths per 100,000 pregnancies (compared with 1 per 100,000 in Belarus and 28 per 100,000 in the US). As a system the UK was ranked the best in the world for health access, efficiency, effective, safe and coordinated care (Commonwealth fund, Mirror,Mirror 2014). However, it currently spends only 9.1% GDP on healthcare or US$3,598 per person, which is free at the point of service. [2] The US spends over twice as much (17.1% of GDP or US$9,146) and was ranked dead last in the same Commonwealth Fund study. [3]
So, to sum up, you’re faced with a well-liked, efficient, life saving machine. So you won’t be able to try a head-on approach, public opinion will need to be swayed first.

Step Two
Misinformation: the great thing about the NHS is most voters at any given election will not have a vast deal of deep experience of its services. To many people the NHS is for shoulder physiotherapy and antibiotics for a chest infection and maybe the odd stitched wound at A&E. This is to your advantage! Start early on by pervading a helpful message of ‘improvement’ and ‘efficiency’. Steer every news piece towards this same message, regardless of context. Be consistent with this message and quickly this will become the ‘norm’. You will need some national newspapers on side to keep this reinforced. Before you know it the NHS will be percieved as ‘failing’. But that won’t be enough!

Step Three
Divide and conquer! It doesn’t matter what you campaigned on- once you’re elected you only have to apologise occasionally and you can do whatever you want! Push through some major reorganisation as early as you can- use words like ‘transform’, ‘power’ and ‘into the hands’. These will keep everyone in service on the back foot trying to respond. Make sure any change is extremely complex- this has two advantages; A) it makes it difficult for opposition campaigners to create ‘headline’ zingers against you and b) this is your opportunity to lay some legal horcruxes to build your platform!*

Step Four
Wash your hands early! If you want to sell off a national institution you have to make sure it’ll slide away easy. When no one is looking, make sure the government no longer has a legal duty to provide the NHS. But don’t stop there! Now is your chance to plan ahead!

Step Five
Open market! Everyone knows they get a better deal when one supermarket opens next to another one! Despite there being absolutely no evidence this applies in any way to healthcare provision! Use that knowledge to your advantage! Use words like ‘competition’ and ‘drive up performance’ – the more you can paint the NHS like a car the better- people like to sell their cars. Meanwhile once the law has changed,  open up the NHS to private contracts bit by bit. This will mean if anyone kicks up a fuss you can say ‘come on! It’s only 4%! It’s only 8%! Etc’. When the numbers start to get bigger use the relative percentages ‘It’s only increased by 15%!’. Useful phrases here are ‘can we please focus on the bigger picture?’. But then what about the staff on the inside?

Step Six
You do have a problem here: much of the NHS staff will see what’s happening, and people will listen to them if you don’t do something about it! Politicians are the least trusted individuals in the country, while doctors are the most; start early on with subtle denigration of the perception of all NHS staff. Take any news report about A&E or midwives or doctors or nurses and make sure someone high profile gets on a box and sticks it to them. Appoint a health secretary who will regularly inflame the situation- this will create distraction from the sell off! Frequently offer empty re-organisations that both fail to address and belittle any problems. Then get down to business.

Step Seven
The money! Cut it, and cut it hard. People use A&E and the GP the most- keep these areas stripped of cash and drive up demand by demanding people go at any time of day- encourage your health secretary to do exactly this! Once these areas go too far under they’ll sink by themselves- locum agency costs to cover staff gaps will cripple failing departments, and smaller GP closures will domino into bigger ones. Obviously don’t be seen to be thrifty- use words like ‘efficiency savings’ and ‘reform’, and above all ‘austerity! But do cut services away- the more gaps you can create the easier it will be for private companies to fill them! Put pressure on the very front services by cutting departments like a and e and maternity, and sell off the backend like microbiology and biochemistry, because no one really understands this stuff anyway.
Make sure you use this opportunity to crush the spirit of the staff- cut their pay, at least in as boring way as possible, e.g by pay freezes and under inflation changes. In the meantime try to award yourself a huge pay rise- this sell off is hard work you know! Doctors and nurses will leave, temporary agency staff will come, the service will worsen and the People will suffer! Now it’s time!

Step Eight
It’s showtime! If you’ve followed the above steps then this last will be a doddle. You’ve got a demoralised and depleted workforce, an unhappy electorate and you aren’t even spending very much on it all! You’ll need to do some hand-wringing, some lamenting, some explaining away. You will find these phrases useful; It’s ‘an ageing generation’, 21st century demand is too much, and ‘the burden to the taxpayer’. And then roll them in- hopefully by this time you should’ve got private companies into at least 20% of services.

Step Nine
Sit back and relax! All your hard work no doubt has been a lot of stress. And those long hours of drinking and smoking and missing the gym have really taken their toll. You deserve some time off! Don’t worry about the newspaper backlash- it’ll come eventually, and there won’t be a hint of apology as the same papers that supported you will hypocritically tear you down. And don’t worry about that chest pain you’ve been having! You’re insured right? Oh you lost your job? But what about the end game- the cushy seat on the board of the health companies? Oh, you’re politically toxic now and all those backroom offers disappeared? And you didn’t save anything?

Oh.

Goodbye.

Re-printed with kind permission @ juniordoctorblog.wordpress.com

*if you have to bridge an election with this still hanging over you just apologise for it! Say it was a big mistake. Then once you’re re-elected you don’t have to do anything about it!
[1] http://www.kingsfund.org.uk/projects/bsa-survey-2013
[2] http://data.worldbank.org/indicator/SH.DYN.MORT?order=wbapi_data_value_2013+wbapi_data_value+wbapi_data_value-last&sort=asc
[3] http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror