Wider political context underlying the NHS junior doctors’ dispute
BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h6317 (Published 24 November 2015) Cite this as: BMJ 2015;351:h6317
All rapid responses
Dear Editor,
We are writing in response to David J Hunter’s article on the junior doctors’ dispute, which highlighted the resurfacing of the “unhappy doctors” syndrome, as a manifest of the dispute over the proposed Junior Doctors Contract. At our busy district general hospital in England, we were interested in how junior doctors viewed the proposed contract changes, and the effect on staff morale.
Among the junior doctor respondents at our hospital, 85% strongly agreed that the proposed Junior Doctors Contracts will harm the long term future of all medical professionals (from juniors to consultants), and indeed 85% also strongly agreed that the proposed contracts will harm the long-term future of the NHS. This echoed the thoughts of the author - ‘no matter what the rights and wrongs of the dispute, the ramifications will be felt throughout the NHS for some time to come’.
The current Conservative government has stated repeatedly that the new contract would improve patient safety; 92% of our respondents disagreed with this. What is more unsettling for the future of the NHS is that 61.6% of those surveyed said the proposed contract had made them think about leaving medicine, and a greater number (69.2%) were now thinking of working abroad. Only 23.1% could see themselves working in the NHS for the foreseeable future. This combined loss of expertise and front-line staff would be detrimental to the NHS, and contribute to the UK ‘brain drain’.
Hunter highlighted three areas that led to the ‘unhappy doctor’ syndrome- pressures on staff, the need for a better work-life balance, and concerns over patient safety. This was strongly echoed in our questionnaire; 88.5% thought that staffing levels were inadequate, and 96.2% agreed that a lack of permanent staff affects patient care. Pressures on staff was highlighted by 73% who thought that there was insufficient time to provide the care that they would like to, and 69.2% felt they were tired all the time due to long working hours. 88.5% disagreed that doctors are well remunerated for their hours. These figures are not surprising given the recent outcome of the BMA ballot, which voted overwhelmingly for strike action (27,741 doctors).
Our questionnaire findings resonate Hunter’s views. Staff morale among junior doctors at the moment is at an all-time low, and many consider the proposed Junior Doctors Contract to be a threat to the long term future of the NHS.
References:
1) 'Staff Morale Questionnaire' Adapted by Dr Ramesh Mehay (2010) from 'The Assessment of Work Environment Schedule' (AWES) developed originally by Nolan (1998) at Sheffield University
2) 'Wider political context underlying the NHS junior doctors’ dispute' David J Hunter BMJ 2015;351:h6317
Competing interests: No competing interests
1. This conflict is part of the destruction of the learned professions. Traditionally these were the Church, University Teaching professionals, Law and Medicine. Perhaps we could include those like the old-fashioned Bank Manager! Their characteristic was that the most senior practitioners regularly saw the individual client/patient/student. They would ask about your problem, assess your need, offer advice about past, present and future problems and hopefully offer a solution. In Medicine, Diagnosis, and Prognosis that validate the prescription of treatment. The practitioner is autonomous in reaching their decision. This underlies and drives the expenditure of the Health Service. Such autonomy or independence is anathema to any employing bureaucracy as the managers cannot control this process, at least directly. Hence ugly organisations such as the GMC and Nice. The GMC has usurped the duty of the employer to determine clinical competence as opposed to probity, forcing doctors to bear the cost, and Nice to support the State bureaucracy in the task of rationing health expenditure. Nice does the work of the Politicians by declaring that, for instance, a treatment is too expensive to be given to the hoi-polloi. The university staff have been brought to heel by setting up Universities as peculiarly nasty quasi-commercial organisation based upon the ideology of what I like to call American commercial brutal. The Law is being sterilised by attacks on Legal Aid and raising costs of going to Law and by attacks on more objective external standard such as the European Court of Human Rights. The Churches are considered irrelevant but this may well change if criticism of current policies continue. So far the State has not managed to destroy as opposed to damage professional autonomy in Medicine. Of course such autonomy can be even abused but that does not invalidate its need. Inevitably the bureaucracy seeks Guidelines and similar procedures to control this autonomy not-with-standing all Guidelines are out of date before they are written and if they are to be followed, pace GMC and Nice, they are de facto regulations.
2. Nothing happens to your clinical skills if as a senior 'junior' doctor you are made a consultant. If you are a to be consultant you must have been doing consultant work and taking consultant decisions well before such an appointment. It is in the nature of things that all doctors once they start to practice will take very important decisions, even those that involve life or death. How else to you learn your craft? A similar dilemma is faced by the military, particularly the army, the most junior officer or squaddie will in combat be faced with such decisions, involving not only others but also themselves. Concerns over Weekend working concerns confuse clinical care systems with clinical competence.
3. Beware of bureaucratic and political priorities wrapped up as concern for the customer,client or patient. They are all to often self-serving and are like the camouflage or the old-fashioned smoke screen.
Competing interests: No competing interests
One factor not mentioned but likely to be of great importance is the use of statistics on weekend effects by the Secretary of State for Health and the Department of Health.
Studies which are observational in nature and incapable of proving causation let alone indicating the most clinically effective interventions have been shamelessly misquoted as "proving" that there are 11000 excess deaths caused by the weekend effect and that this justifies the imposition of new contracts.
No other area of medical innovation would be allowed to make such far reaching and probably expensive changes without proper evaluation
I attach a typical letter from the DoH
Competing interests: I with other colleagues provided acute medical services at weekends for a number of years with twice daily ward rounds seeing every patient on MAU, rolling reviews of new patients on MAU as well as immediate review of patients on a decision unit for patients referred by GPs
I have always viewed myself as being politically savvy and could enter most informal debates, channelling my A-level in history as the tool to understand the wider context. It has only been since the summer I have realised how naive I truly have been. A recent convert to twitter for means of cardiovascular research networking at a conference and beyond suddenly exposed me to politics that directly affected me with the Junior Doctor Contract. In the summer I was suddenly submerged in the evolving debate which for me started with the #ImInWorkJeremy hashtag. I was exposed to a wealth of information coming out of my smart phone. I was reading entries from bloggers, journalists, politicians, NHS leaders and well informed colleagues. The depth of issues facing Junior Doctors, Medicine and the wider NHS started to make more sense. The historical context started to become more obvious and a common narrative was starting to form from the period of MTAS, the 2008 economic crash, the 2012 Social Care Bill and the May 2015 elections.
The editorial from David Hunter,1 really exemplifies the way I see the Junior Contract issue inform of the wider issues facing the NHS and the medical profession. I have personally seen the Junior Contract debate pull me into the world of healthcare politics. I have given my opinion to an audience in 140 characters and entered debates to get the source of an issue or inform a view. This was even involved me entering a twitter discussion with Jeremy Hunt himself. I have felt engaged and passionate about wider politics and even found myself actively campaigning, including attending the London protest march and being involved in a local news piece for my community.
The standout achievement has been the development in an interest in healthcare politics and the excitement to become involved. Even more fascinating is the evolution of debate and opinion amongst my peers. Before only a keen few seemed to be truly informed and involved. Now an entire generation of Junior Doctor has become involved in the current debate and the wider political context. Social media is always a small subset of a larger group and tends to those that shout the loudest, but increasing numbers are writing media pieces, posing for photos and engaging with the public. We now start to see a wider awakening to the politics of the NHS and the challenges it faces. One might see this as a turning point for the NHS because of a perfect storm of events over the last two decades that have created the moment when a professional group as one enters politics and hopefully changes things for the better.
1. Hunter DJ. Wider political context underlying the NHS junior doctors’ dispute. BMJ. 2015;351.
Competing interests: No competing interests
Re: Wider political context underlying the NHS junior doctors’ dispute
There are two major, and only partially addressed issues with the current conflict between Jeremy Hunt and doctors. Firstly, as one responder has already reminded us, there is no evidence whatever that excess deaths at weekends are anything to do with doctors, Secondly Mr Hunt appears not to have noticed that trainee rotas already cover seven days, so I can fully understand the anger that trainees must feel when they appear to be cast as the villains. This, I suspect, is more important than Professor Hunter's attribution (in part at least) to concern over the government's attitude to the NHS as a whole.
I have heard tales from doctors who have spent hours at a weekend waiting to do an urgent operation because the one "emergency" theatre is in use for another procedure. The major issue is the lack of support staff and facilities at weekends - limited radiology and pathology, and a pared-down surgical facility. It is these problems that must be addressed before blaming doctors and certainly before threatening them.
Lastly there is no evidence that medical strikes affect mortality - something alluded to by Raspe, when he wrote the tales of Baron Munchhausen (two 'h's) in the eighteenth century and recorded that when the Baron hoisted the College of Physicians into the air with a balloon for three days - and the occupants failed to notice because they were too busy feasting - no-one died in London.
I have admired Mr Hunt in the past for making tough decisions but only when he based them on the right facts, the right interpretation of evidence and aimed at the right targets. A fail on all counts this time. Must try harder.
Competing interests: No competing interests