Brexit and the NHS: Just the Facts. Part 4: Show Me The Money

In a multi-part series juniordoctorblog.com looks in-depth at the potential impact a No Deal Brexit will have on the NHS. In Part 1, we looked at the impact on the supply of medicines, in Part 2 we examined the barriers to importing nuclear isotopes and in Part 3 we examined the current NHS staffing crisis through the new lens of a No Deal Brexit.

In this final part, we look in-depth at the NHS books and ask do we have the resources and funding to survive a No Deal scenario?

Before going any further, it’s important to establish a few key facts about NHS funding.

Firstly, as a publicly funded institution the NHS budget is set centrally by government and various affiliated semi-government bodies. In addition several charitable and research organisations donate money and resources for specific NHS services.

Secondly it’s vital to understand that the NHS requires more money each year than the previous, to maintain the same standard of care. There are many reasons for this, the smallest of which is an expanding population. Currency inflation is another. However, the main reason is something called “health inflation” – above currency inflation, this is the concept of the continuous rise in costs in any state of the art healthcare system. This takes into account things like the rising cost of new medicines and new technologies, an ageing population, and more and more people surviving conditions that previously would’ve been fatal, therefore going on to require more complex and advanced healthcare. This has been the case for 70 years. Since the beginning of the NHS activity has increased by roughly 4% every year, and the NHS budget on average has risen by 3-4% every year in step.

So what’s going on right now with NHS funding?

Since 2010 there has been a near funding freeze on the NHS, with the budget rising just 0.9% every year, while demand and activity relentlessly grow. The NHS ran a surplus of £1.5bn 2010/11, it now runs an underlying deficit of up to £5.9bn in 2017/8. Increasing service activity have been paid for by a combination of backroom cuts; selling assets like land and transferring investment budgets into day to day running costs, as well as front line cuts: mental health nurses, closing maternities and A&Es, cutting nursing bursaries. Year on year the NHS in England has had to stretch more and more from the same budget, for 8 years.

Wasn’t this a good thing? More efficiency right?

The NHS was already ranked one of the most “efficient” healthcare systems in the world in 2012- mostly due to primary care triaging, the lack of insurance paperwork and payments bureaucracy and use of generic medications.

There is always room to improve however, especially in an organisation with a budget of £115 billion a year. The Carter report suggested getting rid of unwarranted variation in procurement and practice between hospitals could save as much as £5billion (albeit correcting some of the identified areas would take significant investment itself).

However, there is only so much fat to trim, in what was already a comparatively lean system. Relative to inflation the NHS has already cut pay to its staff for the last 8 years, in some staff groups as high as 25%. The land has already been sold, all the clever accounting cards already played. The deficit is £6bn and the NHS already predicted it needed £30bn by 2020 just to keep the lights on, and has only received £4bn to date.

Everywhere the alarms are suggesting there isn’t much more to give: A&E waits are the longest ever recorded and the target has been scrapped, operation and cancer waiting times are at all time highs and staff morale is at rock bottom.

This was the situation BEFORE Brexit.

How does a No Deal Brexit change any of this?

In addition to the additional costs to import medicines and isotopes across new borders, and the agency fees to fill vacancies we cannot recruit to, No Deal Brexit will hit the NHS in the one area it is threadbare; it’s pocket.

A No Deal scenario effectively removes the U.K. from the free trade area of the EU, an economy worth 22% of global GDP, and the 60+ countries the EU has FTA agreements with: Canada and Japan most recently. Once out of FTA trading these countries would be obligated to charge tariffs on exported goods and supply chains based in the U.K including car manufacturing, farm produce and pharmaceuticals. With loss of the financial ability to “passport” services to the EU the financial services sector, 6.5% of our economy, would be hit very hard. The Department for Brexit’s own figures estimate a No Deal to cost £159bn to the U.K. economy by 2030. That’s the entire NHS England and U.K. schools budget combined.

But can’t the U.K. just make our own trade deals?

Potentially yes, but there are multiple barriers to making that a reality: negotiation time (usually years), the approval of the other WTO states and even potentially the approval of the EU with countries like Canada and Japan as part of their FTA in the first place. Most of the “high profile” trade deals we are courting lately; South Africa, Canada, Japan, are all countries we ALREADY have excellent trade deals. For example, the South Africa-EU FTA allows us tariff free trade on 90% of everything we exchange: a deal that’s already increased bilateral trade by 120%. If we do renegotiate we do so from a weaker position; a much smaller individual economy, with weakened buying power, in a desperate position. Secondly pretending these are deals which will equal the loss of trade between the U.K. and the EU in the event of No Deal doesn’t add up: 50% of foreign trade is done with the EU, our next largest partner is Germany by itself, at just over 10%. The USA is close behind with ~10%. South Africa is <1%. If we lost 20% of trade with the EU we would have to increase trade by 100% with the USA to compensate. Countries we already trade with and many that we have free trade agreements with right now.

So a No Deal Brexit will hit the economy a little, what’s the big deal?

In healthcare money means lives. Less money leads to less resources which in turn causes more harm and more avoidable deaths. An analogous scenario is the 2008 financial crash. Fraudulent banking practices in the US housing market triggered a worldwide recession as major banks that had bet heavily on dodgy mortgage products lost, and went bust in the process. Worldwide in countries where healthcare was linked to employment, there was a spike in cancer deaths, estimated at 500,000 excess deaths that otherwise wouldn’t have occurred.

In the U.K., due to the NHS model, we were insulated from this effect. The decision of the Tory coalition however to impose austerity in response to the financial crash had its own effects. A study in 2015 and a further study in 2017 concluded that as many as 50,000 “excess” deaths occurred between 2010-14 and up to 150,000 by 2020 due to cuts in health and social care. With the lack of staff, lack of resources and general decline in every outcome measure of safety and quality this is no surprise.

We are in the exact same scenario as 2008 once again, except this time the NHS is not in good health going in. Despite all this, the current government seems unwilling to countenance the realities. Theresa May even linked her proposed funding increases for the NHS, £20bn a year extra by 2021, to a Brexit “dividend”. *Sigh*.

Is there a Brexit dividend?

Short answer: No

Long answer:

Each year we pay £13bn into the EU and get around £7bn back as an immediate rebate, and then further subsidies, for example to British farming, leaving £6bn going to the EU each year, or £120m a week, or 26p a day per person.

For that amount we have access to 27 Free trade countries worth £350bn a year to the U.K. in trade, as well as 60+ further countries via EU agreements. The CBI estimates this is worth £3000/year per household, or £2 a day per person, eight times what it costs.

In the event of leaving the EU, we gain the balance contribution, but the trade we lose has to then be factored in, the corresponding hit to the economy and the subsidies we would then have to pay ourselves to our own industries. The OBR already estimated we have lost £15bn in economic activity due to the Brexit vote, and even if that were not the case and there were really was a Brexit dividend the government has already promised to spend it several times over.

Specific post-Brexit spending has been promised to: a U.K. satellite system (£100m), a new customs solution and border infrastructure (up to £20bn), storing 6 weeks of medicines (£2bn), a “divorce bill” (est. at least £18bn by 2028), several thousand more civil servants and customs officers, new staff for an expanded civil aviation authority, a new border solution in Northen Ireland, an entirely new authority for food and animal trading and new lorry waiting parks to mention but a few.

On top of that the missed opportunity of firms taking a look at the chaos and uncertainty and deciding to contract elsewhere. Whatever tiny amount we get back from the EU is going to be lost in a deluge of direct and indirect losses.

What does that have to do with the NHS?

Despite promises of another “£20bn” for the NHS, budget after budget will have black holes that need filling, and the chance of any new money, let alone current funding, becomes more and more remote.

Meanwhile, demand will continue to rise. There will be 3,000,000 more over 80s in the U.K. by 2037, a group of patients that costs an average around £7000 a year in healthcare. Increased survival, technology, wage inflation and likely higher currency inflation will all continue to increase the cost of the service we currently have.

Are you done now?

Nearly.

To be very clear, the crisis state of the NHS is not the fault of Brexiteers and voting Leave was not a vote for this. Be that as it may, a No Deal Brexit reality will throw up new barriers to importing medicines and isotopes for cancer diagnostics, push existing EU staff away and stop new staff from coming, and throttle any hope of new funding. Worse, when we should’ve spent two years debating about how to fund the health and social care system we have, how to staff it and supply it, we’ve been talking about Brexit. All other political issues have also been put on hold; teachers, policing, welfare. Brexit isn’t the root cause of the NHS’ problems, far from it, but it may prove to be the straw that broke the camel’s back, a No Deal scenario even more so.

Informed consent is the absolute bedrock of medicine. It’s my job as a professional to fully inform you of the options and you then make a decision knowing every risk and benefit. I’ve never heard a position on Brexit that involved Euratom, the EMA or EU nursing applications. Who knew this stuff? I have to admit, I didn’t. Find me someone who voted Leave that did. I haven’t so far. We can now see the shape of Brexit, for the NHS at least, you are now properly informed. Democracy requires everyone has the same set of facts before they make their opinion. Here are the facts.

The question is what are you going to do about it?

Juniordoctorblog.com

References

https://en.m.wikipedia.org/wiki/List_of_the_largest_trading_partners_of_United_Kingdom

https://www.google.com/amp/s/www.bbc.co.uk/news/amp/uk-politics-42559845

https://www.kingsfund.org.uk/projects/nhs-in-a-nutshell/nhs-budget

https://www.kingsfund.org.uk/projects/nhs-in-a-nutshell/how-nhs-funded

http://www.pharmatimes.com/news/nhs_bodies_delivered_1.5_billion_surplus_in_201011_980543

https://www.nuffieldtrust.org.uk/research/the-bottom-line-understanding-the-nhs-deficit-and-why-it-won-t-go-away

https://www.google.com/amp/s/www.telegraph.co.uk/news/2016/05/25/financial-crisis-caused-500000-extra-cancer-death-according-to-l/amp/

https://www.bbc.co.uk/news/uk-24831941

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

Advertisements

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

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

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

What’s going on with NHS staffing in 2018?

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

What has the government done about this so far?

Short answer: A lot of words and little else.

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

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

What has that got to do with Brexit?

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

How have things changed since the Brexit vote?

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

Are EU staff leaving?

Short answer: Yes

Long answer:

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

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

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

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

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

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

How does No Deal change any of this?

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

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

Is the government doing anything about this?

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

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

What about future EU recruitment for the NHS?

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

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

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

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

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

Juniordoctorblog.com

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What do you mean radioactive?

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

Where does it come from?

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

What is Euratom?

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

Why is that important?

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

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

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

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

Have these isotopes ever run out before?

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

Why is No Deal Brexit different?

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

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

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

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

References

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

https://arxiv.org/pdf/1501.03071

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

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

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

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

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

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

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

Will we still be able to import medicine?

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

Long answer:

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

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

The WTO has its own issues:

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

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

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

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

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

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

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

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

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

What about importing future medicines?

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

Long answer:

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

Why does this matter?

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

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

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

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

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

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

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

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

What about future medicines?

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

The long answer:

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

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

Short answer: Yes

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

Juniordoctorblog.com

References:

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

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

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

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

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

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

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

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

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