Jeremy Hunt interview: Still a safe pair of hands?

Working in healthcare and the training of junior doctors both in clinical and university roles, I found Mr Hunt’s interview depressing on several levels. It is insulting to NHS staff and the public that he spoke of his recognition of the morale crisis in the NHS (but failed to recognise his role), the same unfounded “weekend effect” arguments for his imposed junior doctor contract, and the need for “honesty and transparency”, which he forgot during his closed meetings with media chiefs and mis-use of research data in recent months. Perhaps most upsetting to me, was Mr Hunt’s use of Don Berwick’s recommendations at one point to justify his view of improving the quality of patient care in the NHS.

Last week, at the Royal College of Physicians’ Annual conference in Harrogate, I found myself in tears along with many other members of the audience as Don Berwick, paediatrician and founder of the Institute of Health Improvement, narrated the story of Sean, a child grappling with severe depression among other illnesses. As an adult who had defeated his demons, Sean made Berwick’s day several years later with a surprise visit and a hug, but the story did not end well. A glittering career in the US military was tragically cut short by an aggressive brain tumour. Before Sean passed away, Berwick was able to track him down and attended Sean’s wedding. The uplifting part was the humanity and humility of this world-beating clinician scientist. Equally striking was the fact that public life, international celebrity and science had not reduced, but had rather heightened this clinician’s connection with his patients. Berwick provided a nine-step prescription to preserve patient-centred care and save the NHS, which he felt was threatened by several issues, including the current impasse between junior doctors and the government. He described four initial steps of de-escalation: The first 4 steps were “Stop excessive measurement”, Abandon complex incentives”, “Decrease focus on finance”, and “Avoid professional prerogative at the expense of the whole”. He followed with five steps to improvement, which reinforce the crucial role of research in healthcare.

Step 5: “Recommit to improvement science”. Don Berwick has advised successive UK governments of both major political parties about quality improvement in the NHS and it has been rooted in the science of a discipline over a century old. However, 7-day services and improvement of the junior doctor contract as the major thrusts of current health policy, lack a convincing scientific foundation or a strategy to conduct research which would improve healthcare quality.

Step 6: “Embrace transparency”. Data and evidence trump all, including medical and political careers. The Darzi review, Keogh report, the Francis report and other public enquiries have consistently recommended that research alongside clinical care improves outcomes and saves lives. As evidence-based medicine, data-driven healthcare, and evidence-based policymaking permeate our biomedical norms, it is unfortunate that mis-understanding, mis-quoting and mis-use of research have characterised the current approach to junior doctor contracts.

Step 7 “Protect civility”. Imposition of an unwritten clinical contract has jeopardised the social contract and the morale of a generation of trainee doctors and devalued their professional integrity. A rich evidence base from several countries highlights the deleterious effects of over-worked, under-valued junior doctors on patient safety yet this has been ignored by policymakers. A return to the negotiating table is necessary for both sides of this dispute and only civility can ensure this very distant scenario.

Step 8 “Listen, really listen”. A health system that does not listen and does not learn is against the tide of current expert opinion and research, and a danger to patients. The quality improvement movement supports “learning health systems” and other areas of health policy pursued by the government acknowledge the importance of listening to key constituents, including patients, public and healthcare professionals. Good working relationships between employer and employee, and government and doctor, protect patient outcomes.

Step 9:”Reject greed”. The greed which Berwick referred to was for money and status, which can affect clinicians and politicians alike. This step is perhaps most important in the current dispute. While Mr Hunt’s friends in the media portray junior doctors as greedy for money, this is a worrying distraction from the reality that patient safety plays second fiddle to individual political careers and the 5-year political cycle. The lack of joined-up thinking and long-term vision across politics, policy, science and healthcare and impact on other sectors(e.g. education, environment and social care) are manifestations of greed and need to be addressed far more urgently for patient safety than the junior doctor contract.

Mr Hunt should not selectively quote a great man like Don Berwick. He should instead hear all of what he has to say, which is, in my opinion, very apt to the unfortunate scenario he has created. It is absolutely crucial to start listening to healthcare staff if Mr Hunt wants to seriously pursue his laudable aims of improving patient care and staff morale. Without listening and learning, empty rhetoric and spin will reign.