“You are having a heart attack but we will fix it”. If only everything was so simple.

I’m working my second stretch of nights in a week (due to a missing EU doctor, ironically) on the heart attack service. At 3am my bleep rattles next to me and then shouts “Primary Angioplasty. Inferior MI. 10 minutes”.

This means someone is flying towards us in the dead of night with a major heart attack. Inside, a vessel supplying the heart muscle is completely blocked, the muscle beyond literally dying by the second. Needless to say these patients are very unwell.

The patient arrives and her ECG confirms all our fears: a major heart attack. My 3am brain tries to simultaneously take her history, listen to the ambulance handover, scan her heart muscle and consent her for the procedure all at once. She’s looking very unwell and I’m very conscious of how short time we have. “Time is muscle” in cardiology land, and her heart and possibly life is slipping away by the minute. 

I end up simply saying “You are having a heart attack, but we will fix it”. We rush her into the lab and fifteen minutes later we have indeed fixed it. She’s looking much better and is very thankful. I love cardiology.

Simple eh? From the patient’s perspective she’s had some chest pain, called an ambulance, been told she’s having a major heart attack, and then told it’s been fixed. What could be easier?

Well, pretty much everything. The procedure actually takes at least five people to perform properly, all highly skilled and trained and working together seamlessly. Every bit of equipment we use has been developed over decades, rigorously tested in trials involving 100,000s patients, each part carefully evaluated, checked, stored and audited. The techniques we use, even the pathway itself, has been researched and tried and rejected and trialled again. When this technique was first pioneered many thought it ludicrous. Now it saves thousands of lives every year. Even the basic physiology is incredibly complex.

Which is not to say nothing ever goes wrong- far from it. We routinely have patients who we can’t make better, or don’t get there in time, or need even more advanced therapies: pumps inside the heart, artificial lung and heart machines, emergency bypass surgery, even transplants. There is an entire world behind the curtain that very few members of the public will ever glimpse. And even those who do so directly as our patient do so with only the limited and reassuring perspective of a problem that has been “fixed”. With only a tiny cut 1mm long in their wrist, who can blame them?

Which, by a rather roundabout way, leads me to Brexit. Obviously. This week the NHS and Brexit have been in the news on multiple fronts, mostly raising concerns about the implications of No Deal on the NHS and then some unbelievable absurdity about shortening doctors training times after Brexit to “plug staff shortages”.

The issue we seem to have is one of perspective. There’s too little scrutiny, too much wilful acceptance of “I can fix it”, and not enough people asking “how?”. And especially not enough detail for those of us behind the curtain that can see the vast monstrosity of interlocking gears and cogs that makes up the NHS machine. For those of us that worry Brexit, especially No Deal, will be a sledgehammer to a system already straining under pressure.

Take for example the No Deal scenario. Overnight we will leave the Customs Union and European Medicines Agency, meaning importing medication will require new licenses and tariffs, infrastructure we don’t currently have. Insulin has been the much lauded example– used by nearly half a million patients in the U.K., only one small factory in the U.K. makes any at all, enough for 1500-2000 patients a year. The rest (99.9%) is imported from France, Denmark and Germany. On day 1, with No Deal, there would need to be additional customs infrastructure to even EXPORT to us. In places like Germany where there wasn’t before. The new Health Secretary, Matt Hancock, has assured us they are stockpiling for contingency planning for this event. But insulin needs to be refrigerated, and we are talking about half a millions patients a year. I want to see the detail, I want to see the benefits of this plan, I want to see the mechanics of the machine before I accept this is even possible. So far I have yet to be convinced.

Similarly, Steve Barclay, Tory Health Minister, made headlines on Friday claiming that Brexit will be good for the NHS, claiming the EU forces U.K. doctors to qualify in five years minimum and we could shorten this to “plug staff shortages”. But behind the curtain we know nearly all U.K. medical courses are five years already, some graduate entry courses are four years (although some have switched to five now) and count the first year of work as qualification to meet the EU technical requirement. We know we can’t shorten medical school beyond four years due to the sheer breadth and intensity of work, and the reason most U.K. medical schools opted for five years in the first place. This suggestion will have no practical impact on doctor numbers, but might make undergraduate medicine overly pressured or dumbed down, and will only affect <25% of graduates regardless. And no mention of the 10% of U.K. doctors from the EU who already risk losing their right to work, to healthcare and to pensions here in the event of No Deal. It’s this nonchalant and worse, unchallenged, Brexit commentary that doesn’t inspire confidence amongst medical professionals. We doubt that our government understands the dangerous and complex machine they are tinkering with. 

Similarly Theresa May proposed a welcomed £20bn injection of funds into the NHS, but then predicated that on a “Brexit Dividend”, a dividend nearly every single economist agrees doesn’t exist, a dividend for which no legitimate cases has been made. It’s hard to trust a government that seems to speak to us without any substance. No wonder a majority of U.K. doctors support a referendum on the final terms. 

In the healthcare profession we have a pathological abhorrence to unsubstantiated claims. To b******t. Colleagues that say they will do something and then do not are unreliable, and unreliability is dangerous. Bald-faced lying is even worse, and the GMC hold us to a standard far higher than any politician. A lack of basic probity will get you suspended or struck off, such is the bedrock of trust that the practice of medicine requires. Trust between ourselves and our patients, and trust with each other. And the highest sin of misinformation? Wasting the most precious resource we have; time. Time is muscle. Time is life. Time I waste with you I could infuse into someone else, time that could make all the difference. And for Brexit time is running out. 

Despite occasional appearances suggesting otherwise, medicine teaches you a universal truth: nothing is simple. Absolutely nothing worth doing is easy. The Brexiteers waving away the potential healthcare disasters ahead think they are riding a tricycle down a garden path, that they can flick a wrist and change direction on a whim, when really they are aboard a runaway freight train, heading for a cliff.

We need to start hearing some practicality, we need to start seeing some understanding of the complexity of the machine, of the extraordinary stakes ahead. We need less of the perception “everything is simple”, and more of the reality: this is complicated, this really matters, lives are literally in the balance.

Please fix it.
Juniordoctorblog.com

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Family separation is beyond inhumane, this is state sponsored child abuse

My daughter’s first pair of shoes were a present from her aunty. A palm-width long, green-grey dotted with gold stars, white sole, single Velcro strap. She’d been running around with that manic toddler waddle for a while, the eye watering one where every step seems to just save them from face planting to the ground. Probably a little overdue, her shoes were an instant passport to a whole new world of roaming. She could now run unhindered in the playground, in the shops, down the street to her aunty’s house. As you can imagine her shoes brought her unfettered joy, the innocent happiness of a child. She loves her shoes, she grabs them at every opportunity and rushes to the door, even grabs my trainers and tries to put them on my feet if Daddy is too slow.
My daughter looks down at her feet in the exact same way the little girl in this picture does. Her mop of wavy dark brown hair looks just like hers. When she cries, my heart breaks. When I look at this little girl staring down at her shoes, and moments later crying for her mother, I see my own little girl. I cannot stomach it.

The US-Mexico border has been a contentious issue in US politics since before Trump began his populist anti-immigration drive that propelled him into the White House, but his ever-escalating rhetoric has led here. The chants of “build that wall” have morphed into a horrifying reality: children and even babies in actual cages. 

Despite the Trump administration protestations that “this is the law” the legal situation that has suddenly seen thousands of children taken into state custody and separated from their parents is not quite as simple.

Entry into the United States outside of a recognised port was previously prosecuted in civil court. Pre-trial incarceration used to be the exception, not the rule. Child caring responsibilities are supposed to be a mitigating circumstance AGAINST jailing parents. Children are only removed if there is concern they are being abused. Imagine being arrested pending trial for not paying parking tickets, your child forcibly removed to state custody, a state system without the capacity or will to reunite you. 

The decision to prosecute and hold both illegal entrants and asylum seekers as criminal cases, not civil, is the “zero tolerance” policy of Attorney General Jeff Sessions and President Trump. Children cannot accompany their parents to prison, so they are separated at the border, as stricken mothers and fathers are told their child is being “taken for a bath”. The next thing they are told is they won’t see them again. 

Why is the Trump administration pursuing a policy so inhumane and so cruel? A policy that has created a huge national and international backlash? The party line is “it’s the law”, or “it’s the Democrats law”. These are plain lies. George W. Bush signed the last legislation covering family separation for immigrants, passed overwhelmingly by both major parties. 

Looking beyond this front several officials have admitted this practice is a deterrent, deliberately punishing families that cross illegally. Punishing children, potentially irrevocably so.

Even worse, in response to the international outrage Trump has proposed any new legislation to end family separation is linked to funding for the US-Mexico border wall project. In other words, he will release the children when he gets his money. A United States President, holding children hostage.

At the same time Trump has announced they will pull out of the UN Human Rights Council. For an administration completely lacking in any humanity this seems appallingly appropriate. 

As a doctor, I know the physical and mental cost to the children who are put through such a trauma is heavy. The American Academy of Paediatrics has publicly condemned the practice, equating the psychological and developmental harm this causes to child abuse. 

As a father, I can’t stop looking at this picture of this little girl with her shoes. I cannot stomach the horrifying footage of children in cages. I cannot fathom how any human being of moral conscience cannot see the evil in this, or worse, try to defend it.

The American Civil Liberties Union is currently in the process of suing the government in a national class action suit to desist and reverse the policy of family separation. You can donate here.

President Trump will visit the U.K. in early July. If you believe this policy is a stain on any decent society, come to London or Scotland or wherever he scurries to and let him know.

My daughter’s shoes bestowed a gift of freedom and happiness. This little girl has neither. Our children will one day ask us where we were and what we did during this turbulent period in history. I want to be able to look my daughter in the eye and tell her humanity and decency prevailed because we stood up for it. 

So stand up.
Juniordoctorblog.com

Dear (brand new) Doctor…

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

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

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

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

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

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

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

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

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

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

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

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

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

13. Take all your leave. Go on holiday. 

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

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

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

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

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

19. Try your best, always.

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

It is genuinely the most wonderful job.

Good luck. You will be brilliant.
Juniordoctorblog.com

This is everything wrong with Jeremy Hunt’s tenure as Health Secretary

Yesterday in the Mail Hunt made at least two completely bogus claims;
1. He ‘won’ the judicial review into imposition and gained High Court backing for the junior contract

2. Post Brexit he is going to remove foreign doctors and replace them with ‘homegrown’ trainees 

There’s been enough of heated opinion lately- so let’s just serve cold hard facts.
1. The Justice 4 Health team took Hunt to court on three premises- that a) he does not have power to impose the contract b) that he acted without clarity and transparency and c) he acted irrationally. Despite a lot of press spin saying Hunt won, he actually just dodged the issue, by claiming that he never imposed and ‘no junior doctor’ thought that he was. As in last week’s blog here is the many instances that Hunt said he was. 

The case pushed Hunt to clarify in law that he isn’t imposing the contract, simply passing the buck to local hospitals. The judge also found he could’ve acted with less ambiguity but found it hard to demonstrate the high legal threshold for irrationality.

So far from ‘winning the case’, Hunt was forced back from claiming falsely he was imposing leaving local negotiations with hospitals now a real possibility.

Secondly, Hunt’s plan to replace foreign doctors with ‘homegrown’ talent is as laughable as it is xenophobic.
We are already in the midst of a workforce crisis- applications to medical school dropped 13.5% in the last 5 years, and increasing numbers of junior doctors are leaving training and the country. On top of this, the existing doctor workforce increasingly cover the work of two or more doctors- 7 in 10 doctors work in departments where at least one doctor is missing, 2/5 of consultant posts are unfilled, and 96% of doctors work in wards with nurse shortages. 
To add insult to injury, health education England, the body that funds training of so-called ‘homegrown’ talent, has had its budget slashed by £1 billion next year– all on Hunt’s watch.

Now around 25% of the doctor workforce are non-UK, and 10-15% of all NHS staff. 

We are well below the European average in hospital beds per person and doctors per person in the NHS as we are- yet Jeremy Hunt plans to push away up to a quarter of the workforce, cut the training budget to train less doctors who are already doing two or more doctors work, and make no plans to actually address the drop in ‘homegrown’ talent already, a direct repercussion of Hunt’s own morale plummeting war against the profession. 
Those are the facts. Unfortunately if you read the Mail comments you will see why Hunt would ignore them; there’s a segment of the populace that laps up this anti-immigrant posturing, even if it’s completely insane as an actual plan. 

This is everything wrong with Hunts tenure as Health Secretary- politics before policy before patients. The NHS will only continue to suffer if it goes unchallenged. 
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.

How To Sell Off The NHS: A Users Guide

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

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

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

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

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

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

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

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

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

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

Oh.

Goodbye.

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

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

Happy Birthday: The National Health Service

You might not know this, but it is the NHS’s birthday today. It will be the tender age of 66-years young, born on the 5th July 1948. For those of you thinking of cracking jokes about ‘retirement’ age, please don’t. At the time, The Guardian hailed it’s creation “not as an achievement, but an opportunity”[1]. I wonder what they might have meant by that, and what they might make of the NHS today? Reading through the comments from last week found some old myths about the NHS resurfacing. I thought it might be worth looking a bit closer at a few of the common ones, with a bit closer eye than the standard Daily Mail monocle.

Myth #1

The NHS is already too expensive

Here is how much the UK spends on healthcare (both private and public expenditure): 9.4% of it’s GDP annually in 2012. Which is equivalent to $3647 or £2126 (at the time of writing) per person per year, or £177/ month. 82.5% of that is public money, i.e the NHS.

http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS?order=wbapi_data_value_2012+wbapi_data_value+wbapi_data_value-last&sort=desc

Here is how much the US spends on healthcare: 17.9% of it’s GDP annually in 2012. Which is equivalent to $8895 or £5195 per person per year, or £432/month. 2.44 times as much as we do. 46.2% of that is public money, and 53.8% is paid through private insurance companies or directly out-of-pocket.

In fact, in 2012, the UK was ranked 29th on the list of countries spending their % GDP on healthcare, a list that has not only Canada, New Zealand and the US ahead of us, but also the Marshall Islands, Serbia and Moldova.

The bottom line: We don’t spend very much on healthcare compared to the rest of the world.

Myth #2

The NHS is rubbish

As above, 82.5% of all money spent of healthcare in the UK is public, mostly NHS money. It’s very hard to extract how good a job any healthcare system does, especially between countries where the populations and local factors are so varied. But here are the stats.

These are the all-cause mortality figures for the UK from 2012/3;

Maternal mortality ratio: 8 deaths per 100,000 live births (Joint 8th in the world)
Mortality rate per infant 4 deaths per 1,000 births (Joint 4th in the world)

Life-expectancy at birth: 82 (Joint 2nd in the world)

These are the same figures from the US from 2012/3;

US:
Maternal mortality ratio: 28 deaths per 100,000 live births
Mortality rate per infant: 6 deaths per 1,000 births
Life-expectancy at birth: 79

Bottom line: The vast majority of healthcare in this country is NHS-led and, despite spending less than half as much as our American cousins, has much better outcomes for pregnant women and marginally better outcomes for children and a longer life expectancy, by three whole years.

http://data.worldbank.org/indicator/SP.DYN.LE00.IN/countries

Myth #3

Private care is better than NHS care

I looked very hard for some proper, rigorous, scientific trial looking at this but it isn’t out there as far as I can see. But, as pointed out above, in a country (the US) where 54% of the healthcare is private, health outcomes are poorer than in a country where 85% of the healthcare is publicly provided.

If you take the amount above as everyone paying for his equally- your NHS care costs £177/month. For that, you are covered for nearly any serious health condition, unlimited GP attendances, hospital stays, surgeries, imaging, lab tests- the lot. That’s not to say there are few things not covered by the NHS- but you’d be hard pressed to find them on private health plans. In fact, hunting around on private healthcare websites, I struggled to find any plan that could provide a similar service to the NHS- and remember these plans often include NHS services such as hospitals, radiology departments and staff members, plus you still have to pay your taxes.

On an anecdotal level, people’s perception of private healthcare is wildly different from the view of healthcare professionals. If you are having a minor op, a knee replacement or hip replacement, by all means, you will enjoy the private side room, the better food, the quicker scans and appointments and physiotherapy. But, although it doesn’t seem like it to you, to any doctor you are relatively well.**

When you are really sick, when you need to go to intensive care, or are in a car accident, or have a life-threatening heart attack, seizure or head injury, you do not want to go ‘private’. You won’t want better food or satellite television and you especially do not want to be shut away in a side room- those are times when those commodities are dangerous. You want the same attention from teams of healthcare professionals that Joe Bloggs gets- because they deal with conditions like yours on a daily basis, and no one will ask you to mortgage your house to pay for it.

Myth #4

The NHS is failing

In 2010, according to the Kings Fund British Social Attitudes survey, public overall NHS satisfaction was 70%- an all-time high.

In 2013, despite a record fall, public satisfaction with the NHS was up to 63%, the third highest since records began in 1983.

http://www.kingsfund.org.uk/press/press-releases/public-satisfaction-nhs-stabilises-after-record-fall.

Over that same period NHS hospital workloads increased by 5.3%, treating 17.7 million patients in 2012/13.***

The bottom line: Despite year-on-year cuts in budgets, tremendous pressures on A&E, and a 5.3% increase in the workload of the NHS, satisfaction is still high.

In the meantime the government passed the Health and Social Care Act, of which reforms cost the UK taxpayer somewhere between £1.6 billion and £3 billion. The equivalent of 100,000 years of pay for a junior doctor, 100,000 free university places, 2 or 3 brand new hospitals or several round trips to the Moon. I honestly don’t know if this has had any beneficial impact to the patient in front of me, and I’d love to hear from any healthcare professional who does.

For me, the NHS, as it is for so many of it’s 1.7million employees, is more of an old friend. I love it and hate it, loathe it and admire it in a entirely different way to the people who come in and out for such a short time of their lives. For them it’s either the place that saved a loved one, or maimed them. I am honestly not in ‘support’ of the NHS or ‘against’ it. As ever, the real discussion is much more complicated. But please, be fair to it. It is it’s birthday today.

Juniordoctorblog.wordpress.com

*If you live in a country with a similar national institution that conjures such personal and idiosyncratic arguments as the NHS please let me know.

** And more than likely, although you won’t know it as you write your cheque to BUPA, you were seen by a consultant who works in the NHS, in an NHS hospital with an NHS operating theatre staff, anaesthetist and, especially, NHS junior doctors. For those of you not in the know, trainee junior doctors are not allowed to work privately, so any you see in an NHS environment are more than likely looking after you entirely for free. If you can point to any other organisation that would do that, I will eat my stethoscope.

***2009-10 there were 16,806,196 ‘finished consultant episodes’, which more or less means number of individual episodes of illness in NHS hospitals. In 2012-13 this increased to 17.7 million. http://www.hscic.gov.uk/searchcatalogue?productid=13264&q=title%3a%22Hospital+Episode+Statistics%2c+Admitted+patient+care+-+England%22&sort=Relevance&size=10&page=1#top

[1] http://www.theguardian.com/theguardian/2013/jul/05/nhs-national-health-service-beveridge-labour