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

In a multi-part series 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).



The ambulance never came.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

It’s too late.

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

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

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

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

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

Think about that.

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

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


Diary of an NHS Patient – 2017

2nd January 2017
New year, new diary! Just moved to our forever-family home. Nice area, good primary just round the corner for Charlie and we are only twenty minutes from Dave’s work. Only issue is they just ‘downgraded’ our local A&E– but I’m not worried, although Dave thinks I’m a hypochondriac! GP is local and there’s a big hospital a short drive away. Anyway, back to unpacking!

3rd March 2017
Finally got round to signing us all up at the GP- it’s such a faff. They wanted to see all our passports, and could only sign us up between 1-2pm on Wednesday. Who can manage that? Charlie had a cough for a few weeks so that finally pushed us to join. Waiting time bit long though- two weeks! Oh well. He’s fine.

10th April 2017
Still haven’t got an appointment for the GP! Charlie is looking a bit peaky- it’s been too long now. Phoned up for emergency appointments but the GP never has a free slot. I heard from Linda next door they might have to close- can’t maintain the practice on the funding they’ve got. Never mind. Plenty of other NHS GPs around. Even had a leaflet for a private GP through the door today- £40 an appointment. Bit steep. But booked one anyway. Dave didn’t mind.

17th April 2017
The private GP seemed very nice- referred Charlie for lots of tests though. Dave is worried- he thinks it’s a scam. I don’t. I saw the GPs face- he thinks Charlie is really sick. He asked us if we wanted to stay with the NHS- is that really a thing now? I don’t think we can afford any more private tests. He’s sending us to our local NHS children’s department.

24th May 2017
Waiting for an appointment is agonising. Lost our nerve tonight when Dave thought Charlie coughed up some blood. Everyone was a bit flustered so we went to local children’s A&E- except it was closed. Lack of staff. What the hell does that mean? I’ve never heard of a hospital being ‘closed’. What do we pay our taxes for if not the NHS? We got redirected to another hospital, had a minor divorce-level fight outside the A&E and then decided just to take Charlie home. Our appointment is next week anyway.

1st June 2017
Charlie has cystic fibrosis. I’ve spent hundreds of hours looking all over the Internet and everywhere about it. The specialist at the hospital was very nice- but we were still all in tears. We have another appointment next week. It’s still settling in- my child will always be unwell. I don’t know how to handle this. We tried to see the NHS GP this week- just to touch base. They’ve closed for good. I went back to the private GP for an appointment- looked a lot busier. Had to wait a few days this time. Saw a different GP for £50 this time. Wasn’t very helpful. What a waste of money.

10th Oct 2017
Charlie is managing on his inhalers and things. The NHS department at hospital is great- we have the mobile of Sandra, the nurse specialist for Charlie and any problems just call her up. Heard some mutterings about closing the hospital, ‘centralising’ services. Sounds like a good idea, but Sandra reckons many services like theirs will be cut in the reshuffle. Off the record she said the hospital might close entirely. I left pretty frightened, imagining losing such a lifeline for us. Wrote to my MP when I got back. Why are all the NHS services shutting down?

2nd Dec 2017
Sandra called- they are being moved to another hospital, and their service halved. More ‘efficiency savings‘. She’s not covering anymore- it’ll be a duty nurse system now. I did the maths- our local specialist children’s hospital is now forty miles away. Just shy of 45 minutes by car. What we will do in an emergency? Dave is starting to get chest pains when he’s carrying Charlie up the stairs. We can’t afford to go back to the local private GP right now, the next closest NHS GP isn’t accepting new patients. Just ignoring it now, and hoping.

5th Jan 2018
More leaflets through the door- private health insurance companies offering discounts. Our local NHS hospital has just been taken over by a private firm. Me and Dave had a huge row, and then decided to look into private health insurance. We both believed in the NHS, but it’s clear that it’s not going to survive unless the government step in.  Plus Dave is self-employed and so am I- might be a bit trickier. We will struggle through.

20th March 2018
Got insured with Health Co. – few others in the street did the same. Quite steep for me and Dave – lots of cancer stuff on both sides of our family, plus we both run our own businesses. Dave went to  an appointment on the very next day- Health Co. GP sent him straight to the heart doctor at the private hospital. Long story short- Dave needs a stent in his heart- not a heart attack, but pretty close according to the doctors. Thank god we got the insurance when we did. Charlie has been good.

1st April 2018
Dave had his heart op today- says he’s feeling much better. Stayed in a nice room in the Health Co. ward- had to pay an excess though, £500. A lot more than we could afford. Really weird feeling as a 1970s child having to worry about money and healthcare in the UK. Anyway- no worries. Everyone’s at home and everyone’s well.

9th April 2018
Health Co. sent us a huge bill today. They say Dave isn’t covered for his op, because he had pre-existing symptoms. Altogether they want nearly £9,000. We were aghast. We tried contacting the NHS hospital to see if they would cover us – we still pay taxes. An hour of ringing got me to a stressed sounding secretary who just laughed in my face. We tried to move back to cardiology at our local NHS hospital- but they don’t do outpatients anymore. Have to raid the savings, probably add a bit to the mortgage too. Need to get the hang of this insurance business better.

15th June 2018
Charlie is sick again – looks like his cystic fibrosis. Went to a great Health Co. GP who wanted to send us to the Health Co. hospital. The hospital wanted to know is Charlie insured. We thought he was- – the hospital says not. An hour of furious tears on the phone turns out they are right- he was excluded because of his cystic fibrosis from a regular family policy. We could pay out of pocket, but the nice Health Co. GP said that might costs hundreds of thousands of pounds. We’d have to sell our house. So I called Sandra- she told us to drive to her NHS hospital, even though it’s an hour and half away. I never expected to be choosing between  money or my family’s health. How did this happen? Anyway, we drove to the ‘central’ children’s hospital – and they rushed Charlie to their high-dependency bay. He’s stable now. Dave and I can’t seem to talk to each other, every conversation turns into blaming the other for the insurance rubbish. Bad night for everyone.

17th June 2018
The NHS has really changed- much of the hospital is actually just private companies that have taken over different sections. I’m signing all sorts of documents about insurance and waivers and declining ‘optional’ extras. Whole wards of the NHS buildings are empty. It’s scary.  The NHS staff haven’t changed though- Charlie’s paediatric team are the same amazing, hard-working angels they’ve always been. Sandra has been in every day- she looks awful. I’ve never seen her so stressed. I caught her for five minutes to catch up and thank her- I asked her how’s work- and she started crying. Most of her colleagues have left the NHS side, she’s the last cystic fibrosis nurse left in the county for the ‘uninsured’. She gets heartbreaking phone calls like mine every five minutes. She has to turn many of them down. She can’t cope. Every month they get less funding and are told to be more ‘efficient’. She’s close to retirement she told me, so she said she was determined “to see it out”. Her career? I asked. No, she said, “the NHS”.

21st Aug 2018
Charlie is back at home. We did two months driving an hour and a half a day to be with him. We took it in shifts, so Dave and I haven’t really been in the same room for more than twenty minutes for 8 weeks. Our relationship is struggling, but at least Charlie is better. I managed to get him back on a Health Co. policy- but the costs are phenomenal. We had thought about a second baby, and if my business had done better maybe even a third. Now we will settle for Charlie. Health Co. gave us a card to show private ambulances to get to our local hospital. Our GP is private, all of Dave’s cardiology appointments are now private, at huge cost, but at least we are covered.

10th Jan 2019
Dave’s mum had a stroke. She’s 92 and the first we heard about it was a call from a care home telling us she can’t pay. We were shocked. She’d been sent to a ‘central‘ elderly care ward fifty miles away, and then sent back to a care home near Dave’s brother. Obviously Dave’s mum was still on the NHS. Apparently there is supposed to be free coverage for the elderly, but it doesn’t cover care costs. We went to the care home- it seemed nice enough. It’s all private though- the manager was a lovely man, who explained we basically had two options; sell Dave’s mum’s house, the house he grew up in, or move her to the NHS subsidised home a few towns away. We went to the NHS one- bit shocked by how run down it looked. Social care apparently has been cut just as hard as the NHS was– it’s all basically private now unless you can’t afford it. We are selling Dave’s mums house.

3rd May 2019
I found a breast lump today, in the shower. It felt like a hard rubbery knot, just under my right breast. Scared and anxious the first thing I did, still in my towel, was go to the Health Co. policy documents in my office. I read them three times over- trying not to linger on the ‘C’ word, but also making damn sure that if I go to the doctor now, we won’t lose our house. Only when I was sure did I go tell Dave. I felt sick watching his face as he felt it too. We booked into a private GP appointment- have to wait a week now, and still have to pay £60 excess.

30th May 2019
Had all our scans, tests, appointments, re-appointments. It’s a low grade breast cancer. Hasn’t spread- it’s an operation, then chemotherapy for a few years, then done. Sort of relieved, sort of mind-bogglingly terrified. All private staff, all the way through. Dave and Charlie have been very supportive. Hasn’t cost too much in excess payments etc. No holiday this year but let’s get some perspective. Op will be next week.

12th June 2019
Op went well, back at home on tablet chemotherapy. The doctor offered me radiotherapy as well- I thought that was a good idea. Booked in next week.

3rd August 2019
A bill arrived today. Another bill. I can’t cope with this. It’s for some aspects of my cancer treatment- apparently the company made an ‘error’, a lot of treatment was ‘extra-contractual’, bottom line; they won’t pay for it now. The CT scan that gave me the all-clear was ‘extra’, the radiotherapy treatment was ‘extra’, all of the nights in hospital with side effects were ‘extra’. The ‘extra’ cost is £192,000.
I keep looking at that number, wondering how it ever came to this.
My mum had cancer- she had a thyroid lump ten years ago. I went to all her appointments, in and out of NHS hospitals, specialists, scans, surgeons. She’s fine. And she never once paid a penny more than her taxes. What a different world we live in now.

5th November 2019
If I sell my stake in my accounting firm, Dave sells his business and goes back as an employee, and we sell our house and downsize we can just about make the payments without declaring bankruptcy. Charlie’s insurance is gonna hit us hard though.
I saw Sandra in the paper today- I spotted her face protesting in a crowd outside her NHS hospital. Shut down, no funds and not enough staff they say. I text her. She’s retiring now. She’s seen it out, and for her the NHS is over.
For the rest of us as well it seems.

3rd Jan 2020
I did some research. We were all told private companies came to ‘save’ the NHS, that healthcare was no longer ‘affordable’.
But compared to our neighbours the NHS didn’t cost very much- just under 8% of GDP in 2015, well below what Germany and France were spending. We were told that more money was being given to the NHS, but it never really was. Compared with demand the last ever decade of the NHS was also it’s most austere. 
Now we can just get by without the NHS- but only just, and we were fairly well off. I worry for those that aren’t. Every day I worry about the next treatment for Charlie or what if my cancer comes back? How will we afford the co-payments and excess charges?
Now the NHS is still around, but it’s gone in all but name. It’s for emergencies and the unemployed and poor only. Basic healthcare. I don’t pay any less tax- more money goes on my family’s hospital bills than ever before.

1st July 2020
A new government is about to be elected. I’m going to campaign hard for the NHS to return. Too many of us are suffering its loss. But no mainstream party has a realistic plan to restore it. It’s simply too late.

I’d wish I’d done something when I had the chance.

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?
Do no harm does not mean do nothing. If you want justice, for the long term benefit of all of us, do this.

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.

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.

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.

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


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.



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.”

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 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]


  • 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.


It’s The Spin that Wins

The strike is back on and Jeremy is straight out in front with claims of committing ‘extra funds’ to the NHS. Unsurprisingly this is rubbish.

juniordoctorblog explains how the funding spin is constructed and how they are getting away with it.


NHS Funding: Who’s telling the truth?

The funding situation of the NHS can be a tricky thing to get your head around, so it’s no wonder the British media struggle to report it accurately. As such, we often hear statements from the Government and leading health economists that seem diametrically opposite to each other, leaving media reporters, and by extension the general public, confused and unsure of what to believe.

For example, George Osborne in his latest Spending Review can announce a “half trillion pound settlement, the biggest commitment to the NHS since it’s creation”[1]. Meanwhile, the chief economist of the King’s Fund, states the NHS is facing the “largest sustained fall in spending as a share of GDP”[2]. David Cameron can say he’s invested “£10bn more into the NHS” while the chief executive of the NHS is aiming for “£22bn in savings” [3].

Surely these widely varying statements aren’t compatible? So who’s telling the truth?

In fact, all of these statements are correct. No one is lying…technically. To understand how, we first need to explore the concept of healthcare inflation, and how it has affected the NHS budget over its 67-year history. Healthcare inflation describes the long running trend for healthcare needs and costs to rise above the rate of general inflation, and above the average rate of growth in the economy.

One of the most important drivers of increasing healthcare costs is an ageing population. This isn’t a new phenomenon; throughout the last hundred years we have been progressively living longer and longer [4]. We’re also spending a greater proportion of our lives in ill health [5], requiring greater medical care. Another cause of healthcare inflation is new technology – new medical discoveries, drugs and devices – and again, this is nothing new; research and innovation has always been a feature of medicine. So spending on healthcare has always had to increase to ‘keep up’ with these drivers. Before 2010, the annual NHS budget increased by 4% on average, in real terms, year on year since the NHS was created [6]. In 1948, 3.6% of GDP was spent on health, and by 2010 that had climbed to 7.8%[7].

Historically, successive governments have justified these increases because health is important to the British public: a fundamental right, a key part of our wellbeing, an economic necessity for our productivity, and the bedrock of a fair and just society. So actually, increasing expenditure on health is appropriate if we as a nation feel that health is a priority to our wellbeing, and we’re willing to devote a greater proportion of our economy towards it. Nor is this pattern unique to the UK; healthcare costs have increased over time in all developed countries regardless of the type of health system [8]. In fact, we spend less than most developed countries on healthcare [7], with better outcomes [9].

Returning to the present day, the NHS is clearly under pressure. But the Government would have you believe that these pressures exist despite robust investment in the NHS, and that’s where the real deception lies. Rather than being inevitable, the pressures are largely self-created as a result of funding decisions by the Government since 2010.

Yes, technically, there has been a funding increase, and yes, technically, the NHS is a ‘protected department’, ‘ring-fenced’ from cuts. But this increase has been negligible and far far below the demands of healthcare inflation. Over the last 5 years, the health budget grew by 0.8% per year [7], far short of the historical trend of 4%. Extrapolating this difference for a further 5 years works out as a 17% gap (£22bn per year) between needs and funding by 2020. So despite seeming like a ‘protected’ department, the NHS is actually having to make severe cuts, and that pressure is being felt by the overworked and under-appreciated staff of frontline services.

These realities are being hidden from the public, conned by effective spin to believe the NHS has been shielded from austerity. Osbourne’s recent boast of a “half trillion pound settlement” can simply be explained by multiplying by 5 a budget of over £100bn, for the 5 years of the parliament. “Biggest ever commitment to the NHS?” Yes, it is the largest absolute monetary spend, but then, every successive parliament has spent more on the NHS than the previous one [7], so this is meaningless. Cameron’s “£10bn investment” is a paltry sum when spread over 5 years. Yet for all these mistruths, the Prime Minister and his Chancellor are so skilled in PR and careful phrasing, they come out sounding like champions of the NHS, and it’s difficult for the media and the Opposition to challenge their over-simplified sound bites.

The lesson here is that using absolute monetary terms to describe health spending is flawed, because the issue is complicated so much by healthcare inflation. Perhaps a more meaningful way of assessing relative spending priorities is to look at health spending as a proportion of GDP: as a nation, how much of our economy are we prepared to devote to our health? On this measure, the NHS has been falling consistently since 2010 [7], and it wasn’t that high in the first place compared to other countries. With an economy that looks set to grow over the next 5 years [10], and austere NHS spending plans already laid out, the health service looks set to lose out further. Hospital trusts are already running deficits [11] in attempts to maintain current standards of care, but it won’t be long before the impact is felt with longer waiting times and poorer quality of care.

Is this what the British people want? Did the electorate vote for this? In 2010, one of Cameron’s defining campaign slogans was “I’ll cut the deficit, not the NHS”[12]. Similar statements were made before the 2015 election. Given the highly persuasive Government spin, many simply aren’t aware of how the NHS is being starved. This systematic defunding of the health service would be democratically acceptable if, following honest debate, it truly reflected the views of British people. But that public debate never took place, and it’s one that our Government would rather avoid. In politics, it’s the spin that wins.



Image source: The Health Foundation














contributed to JDB by DrWJ