Survey shows low morale in defence medical servicesJunior doctors criticise poor food and accommodationBad habits hit the Health of the Nation targetsA GP salaried service is one optionJunior doctors criticise phasing of pay awardBMA wants no discrimination on grounds of sexual discriminationScottish community care is underresourcedThe BMA will look into needs of prison doctors
(Published 05 April 1997)
Cite this as: BMJ 1997;314:1051
Survey shows low morale in defence medical services
A BMA survey among doctors in the armed forces shows the anger that many feel about recent changes in the services, their lack of confidence in future career prospects, and an unprecedented low morale. The respondents said that they could not remember a time when they had been under such stress.
Over 750 doctors responded to the survey. Over 90% thought that career prospects in the services were deteriorating; more than one in six doctors with over 16 years' service were planning to retire before the age of 50; and only half of those questioned said that they would recommend a cadetship and a short service commission to a medical student.
The survey was anonymous. One doctor said, “Today the biggest source of distress is that the reorganised defence medical service is not capable of meeting its operational requirements, far less provide high quality medical care to service personnel in peace time.” Another doctor commented, “I intend to leave the service as soon as I can if conditions do not improve soon.”
The chairman of the BMA's armed forces committee, Dr John Blair, said, “The results of our survey bear out everything the House of Commons defence committee said in its recent report. We are distressed by the opinions which have been expressed, and urge the government to address these serious problems. The BMA is anxious to support in every way those officers serving in the defence medical services in whatever branch and in particular those charged with the onerous task of leading the services at this difficult time.”
Junior doctors criticise poor food and accommodation
Junior hospital doctors have called for an independent inspectorate to monitor the standards of food and accommodation provided for those who are on call or resident.
The 1991 new deal on junior doctors' hours recommended minimum standards–for example, on call rooms must have beds with a change of linen between each occupant; meals should be adequate and varied; rooms should be well decorated, carpeted, and curtained; security locks should be fitted to residents' rooms; and heating should be adequate and controllable.
Not one of the 120 trusts which the BMA has questioned in a telephone survey complied with the criteria. Less than half provided accommodation which included a comfortable bed; 60% had inadequate heating; less than a quarter provided proper soundproofing; many sites failed to provide adequate security arrangements; and less than half provided decent kitchen facilities. The latter is important when the provision of meals–particularly hot food–is so inadequate.
No hot meals after 7 pm
Although many doctors who use hospital accommodation work throughout the night, the survey found that few trusts provide hot meals after 7 pm; many junior doctors have to rely on expensive vending machines or order take away food.
Dr Paul Flynn, a member of the BMA's Junior Doctors Committee, told a press conference last week that many doctors were prepared to provide video and photographic evidence of their accommodation. Some had reported that bedlinen had not been changed and others that the nearest toilet facilities were in nearby wards. “Less than 20% on call on Christmas Day had been able to get a hot meal.” He hoped that the inspectorate would report to the regional NHS executive offices. Dr Flynn emphasised that the JDC was not calling for a massive injection of funds.
The chairman of the JDC, Dr Peter Bennie, said, “This survey shows that many trusts are cutting corners when it comes to the living conditions of the junior doctors who provide the majority of emergency hospital care. The reductions in hours under the new deal are meaningless for many frontline doctors if they go back to cold food and dismal rooms. Tired and hungry doctors are not good doctors.”
Bad habits hit the Health of the Nation targets
Five years after the launch of the Health of the Nation strategy as the main plank of government policy on health in England, an influential Commons committee is concerned over a rise in teenage smoking and drinking by women.
The public accounts committee reported last month that out of 27 health targets good progress had been made towards 11, particularly on coronary heart disease, stroke, and some cancers. These improvements reflected developments in medical techniques and screening programmes, and the committee has urged the Department of Health to build on the success so far.
The committee is disturbed, however, that obesity in adults has increased. This reflects a long term decline in physical exercise, even though people consume fewer calories. Progress depends on people deciding to alter their lifestyles.
The number of women drinking more than 14 units of alcohol a week had risen to 13% by 1994, against a target of 7% by 2005, with a likely effect on the incidence of disease and alcohol related accidents. The report says that more needs to be done to assess the reasons for the increase so as to devise effective countermeasures through health education programmes.
The committee calls for further action to curb teenage smoking, where the target is being missed.
The committee criticises limitations on the government's ability to monitor progress in some areas, such as the rising number of suicides among Asian women. Nor is there an indicator that specifically monitors the spread of HIV and AIDS. New cases of AIDS have fallen 10% below the number forecast so that spending on treatment and health education has been cut.
A GP salaried service is one option
Last year the GP local medical committee (LMC) conference passed two motions on a salaried service in general practice–calling on the General Medical Services Committee “to negotiate flexible arrangements for general practice which allow those doctors who wish to work in a salaried service to do so” and “to explore urgently the ways of enabling practices to employ accredited GPs who wish to have salaried status.”
A personal paper by the chairman of the Gloucestershire LMC and a GMSC member, Dr Peter Fellows, has been sent to LMCs to help in the debate.
Dr Fellows suggests that a £20 minimum hourly rate would be an appropriate base measure. A standard working week would have to be defined and overtime rates agreed. Out of hours work would be regarded separately although he thinks that some doctors might want to retain 24 hour responsibility for their own patients.
A normal working week should include the time when the GP will accept responsibility for medical care, emergency cover, practice administration, NHS administration, training and teaching, and liaison with other health workers. Dr Fellows envisages a basic working week of 53 hours, including 26 hours of patient contact.
He sees no reason why a salaried doctor should not have a registered list of patients with tight criteria for maximum list size. Seniority payments would be expected and possibly a merit award system similar to that of consultants. He estimates basic pay at £55 120 a year. But total pay for a full time GP taking part in the out of hours service could be about £67 240 a year.
Resignation from the NHS
Resignation is another option Dr Fellows suggests in his paper that if the government refuses to offer a realistic salaried service GPs could consider resigning from the present contractor status. The government would be unlikely to abandon the NHS so it would have to work with a private primary care service. Fees would either be charged directly or charged on a cost per case basis to the commissioning authorities.
The paper proposes a £20 consultation charge, £30 for a visit between 9 am and 6 pm, and £50 at other times. Dr Fellows estimates that GPs could earn £93 600 a year from basic surgery consultations, assuming 26 hours a week patient contact and a 45 week year. Additional work, such as certification, minor surgery, and maternity care, could amount to £13 500 a year. He anticipates that the minimum income for an average list size could be £113 850 a year excluding any out of hours or weekend work. When expenses and a 20% pension contribution were taken into account the minimum pay could be £51 880.
Dr Fellows suggests that if negotiations on the current independent contractor status do not produce satisfactory results by the end of the year the GMSC should consider producing a more detailed analysis of the financial consequences or a salaried service or resignation from the NHS.
Junior doctors criticise phasing of pay award
Representatives of Britain's junior hospital doctors have criticised the government for its “cynicism” in not meeting the recommendations of the Doctors' and Dentists' Review Body in full.
The Junior Doctors Committee has, however, welcomed the review body's recognition that “much more could be done by the Departments and the employers to improve conditions under which junior doctors work” and that “there is now reason to doubt whether much more is likely to be achieved in the immediate future, at least in relation to actual hours worked on call.”
In a composite motion passed at its meeting last month the JDC also regretted the review body's inability to recognise the perversity of the current out of hours rates and said that it was concerned at the continued marginalisation of flexible training and trainees.
BMA wants no discrimination on grounds of sexual discrimination
The BMA has issued a supplement to its guidelines for promoting equal opportunities in the health service on discrimination on the grounds of sexual orientation.
The supplement, which was produced by the career progress of doctors committee, recommends that equal opportunities policies should emphasise that people who are lesbian, gay, or bisexual, and those who are transsexual and transgender, should receive the same protection as all others working in the NHS. This protection should cover recruitment, promotion, training, transfer, terms and conditions of service, and dismissal.
Equal opportunities policies should include sexual orientation in their references to sexual harassment. Everyone in the health service should receive education and training in equal opportunities which should be specific about sexual orientation. The royal colleges and the BMA should take a lead in ending discrimination on the grounds of sexual orientation.
The BMA should ensure that all its staff, particularly the industrial relations officers, receive training in sexuality awareness.
The association should campaign against discrimination against lesbian and gay doctors in the armed forces. There should be equal pension and benefit rights, including married doctors' accommodation for single sex couples.
BMA Services should where possible recommend to BMA members the most suitable range of financial products and insurance companies which do not discriminate against gay, lesbian, and bisexual doctors.
Medical students should receive education on sexuality issues, including the medical care of gay, lesbian, and bisexual, transsexual, and transgender patients, in medical school and during postgraduate training.
A further recommendation that the BMA should give equal membership benefits to same sex couples as they give for spouse membership has been referred to the finance and general purposes committee because of the financial implications.
Scottish community care is underresourced
In its report on community care in Scotland the Scottish Affairs select committee says that community care is underresourced and the funding has been inadequate to meet the government's aims set out in the 1990 Community Care Act. It recommends a wide ranging review of the entire system of providing resources for community care and the development of an agreed set of minimum national standards of community care and suggests a shift in emphasis to examine the outcomes of community care delivery. The committee agrees that nursing care should be free of charge, wherever it is provided.
The BMA will look into needs of prison doctors
The BMA is to investigate the needs of doctors who work in the prison service and government departments and agencies with a view to setting up a representative structure. The association has been receiving an increasing number of inquiries from prison doctors who are having difficulties in exercising clinical independence in their work. Prison doctors and those working in other government departments and agencies lack support systems and many feel isolated from other doctors in the profession. Many of their queries are dealt with by the BMA's medical ethics committee but not all of them come within its remit.
Medicopolitical digest is prepared by Linda Beecham