Why the junior doctors’ strike on Tuesday is essential for understanding the state of our healthcare system and its tireless workers
“You are 15 per cent more likely to die if you are admitted to hospital on a Sunday than if you are admitted on a Wednesday.” Health Secretary Jeremy Hunt, 2015
“6,000 people lose their lives every year because they don’t have a proper seven-day service in hospitals.” Jeremy Hunt, 2015
“It is not possible to ascertain the extent to which these excess deaths may be preventable; to assume that they are avoidable would be rash and misleading.” Sir Bruce Keogh, Medical Director, NHS England, 2015
This is the infamous misrepresentation of a BMJ study, investigating England’s NHS hospital admissions, used as a basis for hugely unpopular, unsafe and unproven junior doctor contract reforms, put forward last summer by Conservative Health Minister Jeremy Hunt.
Since first announcing the proposed contract changes, the dispute between the government and the British Medical Association (BMA), who represent junior doctors, has seen governmental threats to impose the contract anyway, as well as BMA members voting overwhelmingly for strike action (the first doctors’ strike for 40 years), an 11th-hour cancellation of the walk out, threats to forcefully impose the contracts lifted, a second breakdown of negotiations, a second threat to impose the new contract anyway, and, finally, planned strike action by England’s junior doctors, due to start on 12th January 2015 – the first all-out strike in NHS history.
The earlier return to the negotiating table in December 2015, facilitated by Acas, made modest progress but, again, broke down over disagreements regarding unsafe working hours, academic contributions and pay progression. What must be made clear is that this conflict is not about money. Doctors, like everyone, must be paid fairly for what they do without question, but this is about respect, integrity and supporting our NHS. England’s doctors entered medicine for the privilege to heal the sick, and be part of the world’s leading healthcare system. This is not an organisation rewarded for generating profit, but prized for providing cost-effective, safe, patient-centred healthcare; not the impression you would get from the current political rhetoric, despite the NHS being ranked number one in the world by the World Health Organisation.
The contract reforms that Mr Hunt is proposing include supporting the creation of a seven-day NHS, which, apart from already existing, will be done without doctors taking a pay reduction, without doctors working longer hours and without more doctors. In reality, what the new contract proposes is a change in what defines normal working hours, a change in how these normal working hours can be worked and a change in how doctors will be remunerated for providing a 24/7 service, which, again, does actually already exist.
Currently, doctors work a combination of normal, sociable working hours and unsociable hours. Depending on their specialty, the number of unsociable hours worked varies, and generally, they are worked in rotation in order to equally share the burden of covering nights and weekends. In return for their hard work, doctors get paid an overtime rate for covering these hours, which include weekends and weekday evenings from 7pm to 7am. With the proposed new contract, normal, sociable working hours will be re-defined as Monday to Saturday from 7am to 10pm. This not only equates to an approximate 30 per cent reduction in pay, but also a drastic and almost dangerous change to working patterns.
This includes the abolition of the banding system, which currently protects junior doctors and the patients they serve from being overworked. Banding is, essentially, a system that calculates the pay supplement of a doctor depending on how many unsociable hours they are expected to work. It also has built-in safeguards which ensure that doctors are receiving enough breaks and rest, and are not working a dangerous number of hours. Eliminating the banding system would mean conforming to Working Time Regulations (WTR), which does not provide the same level of protection that the current system does. For example, according to the WTR, for every six hours worked, a doctor is entitled to a 20-minute break. In practice, this means that for an 11-hour shift, doctors are only entitled to one 20-minute break. The WTRs also state that the 48-hour limit on a normal working week does not actually apply to the activities of doctors in training.
So unfortunately, Mr Hunt’s claims just don’t seem to add up. When forced to backtrack regarding what the new contract would actually involve, he explicitly stated that doctors would not be made to work more than 48 hours per week and that their pay will not be cut. The WTRs don’t protect doctors in this respect, and he hasn’t offered any alternative for employers to go by. Further backtracking, he then revealed that pay will only be cut for those doctors routinely working more than 56 hours per week, the proportion of which he referred to as a “small minority”. These doctors are not a small minority and they are those working the longest hours. If employing more doctors is not included in the reforms (which it isn’t), these hours cannot be covered without a significant number of doctors accepting a pay cut.
The NHS is currently structured the way it is not only to provide all with cost-effective access to consultant-led care, but also to train, nurture and empower every next generation of new doctors and surgeons. No doctor in today’s NHS works independently; all work as part of a team, headed by a consultant, and include a multitude of allied health professionals, always engaged in education and development through observation, discussion and accumulating experience. This structure is such a vital, integral part of every doctor’s training, and is something that Jeremy Hunt has completely failed to understand. Doctors learn theories and systems in medical school, and their first five years as undergraduates provides a superficial and elementary, yet essential, knowledge and insight into the medical profession. However, the majority of a doctor’s education takes place while they are working, and begins from the moment they qualify until the day they retire.
As a reflection of this increasing experience, and by default, increasing responsibility, doctors are entitled to an annual pay increment, which reflects their increasing competence. The new contract will exclude doctors who are not on a recognised training contract from being eligible for these increments, and will also negatively affect those who take time out of training for academic study or maternity leave, due to their time out of regular work. What is especially frustrating is the complete and utter disregard for the way in which education works within the medical field and the National Health Service, and no admission to the fact that time spent working is education in itself, irrespective of progression on paper. In light of Mr Hunt stating in his 25-year vision speech at the King’s Fund that he wants “learning and continuous improvement at the heart of a more human system”, this doesn’t do much to encourage learning and continuous improvement at the heart of England’s junior doctors. The reality is that places on run-through, recognised training schemes for junior doctors are incredibly competitive, and maintaining a place on one of these training schemes is no different. Most speciality trainees are expected to complete a PhD as part of their contribution to the field, as well as passing numerous (and expensive) exams and various career development requirements.
This is, however, the job, and is what medical trainees are prepared to do. What is unfair is that when taking time to complete a PhD, second degree or even maternity leave, doctors would not be guaranteed to come back to work on an equivalent pay scale. Aside from the obvious and borderline medieval sexual discrimination, this does nothing to encourage any form of academic career development (or anything resembling a near-normal family life). And given that today’s contemporary, evidence-based medical practices that we are so proud of, are built on the research undertaken by academic clinicians, one would hope that they are held with a higher esteem than our current government is portraying.
Incidentally, while taking time out to complete a PhD or second degree, the locum shifts that doctors can work to support themselves in the interim will also be cut and will be subject to a reduction in hourly rates. These changes directly affect specialties like oral and maxillofacial surgery, for example, where it is compulsory for surgeons to have both medical and dental degrees (both of which are five-year courses), as well as completing at least 10 years of post-graduate specialist training. Both degrees are usually self-funded, with doctors often working shifts at night and weekends in order to support themselves while studying (and both, of course, are subject to the Tory-led higher tuition fees of £9,000 per year). The new contract proposals would mean that trainees would be relegated back to the lowest pay scale after completing their second degree, despite having already worked for a number of years in the NHS, and would also have their earning potential while studying significantly affected. Currently, 10 per cent of training posts in this speciality remain unfilled, and with further difficulties placed on pursuing an already challenging, highly specialised career, this number may be set to increase.
The first National Health Service, established 5th July 1948, replaced a system where free healthcare was only available to 43 per cent of the population, none of which included women or children. It also replaced a system where hospital treatment was fee-based, and subject to a postcode lottery where rubbing shoulders with a councillor might guarantee you a hospital bed if you needed it.
When Aneurin Bevan envisaged the NHS in the echoes of a second world war and the shadows of a nation devastated by battle, he envisaged a health service that would be free at the point of need, available for all in need, funded by all in fairness and, most poignantly perhaps, used responsibly. He wanted a system where the responsibility lay at the feet of the Health Minister and was run with the involvement of the nation’s medical staff. In a speech made in 1945, Bevan said, “I know very well that I am not going to succeed in my task by bullying methods.” He believed that doctors, as a profession, must have a greater and greater say in the management of their own service, and his enthusiasm for democratic medicine was as great as theirs. Today, the NHS is shaping up to be little of what Bevan had envisaged. Threats to impose the new contract, despite a cancelled walk-out and a return to the negotiating table, is not democratic medicine.
With the introduction of the Health and Social Care Act in 2012, which saw the devolution of Greater Manchester’s NHS budget, with no real way of tracking where the money is going, vital services being put out to tender to private companies, as well as sustained cuts to the adult social care budget, equating to 31 per cent over the last five years and seeing 24 per cent of adult social care requests being met with no direct support, one would be hard-pressed to believe Jeremy Hunt when we he says that the junior doctors contract changes are not a “cost-cutting exercise” – because everything else seems to be.
The ideals on which Bevan built his NHS mustn’t be forgotten. He believed that the sale and purchase of medical practice was an evil in itself and said, “the most important thing is that a person ought not to be financially deterred from seeking medical treatment at the earliest possible stage…”. He also believed it to be unacceptable that the quality of healthcare should vary by postcode, and that the best possible treatment be available to all, based on need and not ability to pay or geographical location. If budget cuts are needed, our nation’s healthcare should not be an area of compromise. (Incidentally, the Trident Nuclear Missiles will cost an estimated £167 billion to replace, in order to provide the United Kingdom with a deterrent against terrorists fighting a war which Tony Blair half-heartedly recently apologised for causing).
As a nation, we mustn’t forget how lucky we are. The privatised healthcare system of the USA was ranked lowest by the WHO, and is a system where if you don’t qualify for the limited care provided by Obamacare or don’t live in a state that offers it, and cannot afford private health insurance, you are charged a state penalty. Unsurprisingly, more than 50 per cent of uninsured Americans live in the 15 non-participating states – if these Americans cannot afford to see a doctor, they can’t see one until their condition becomes life-threatening.
Another return to the negotiating table would require a concrete resolve on the government’s part to address the issues that junior doctors are most concerned about; calling off another strike at the last minute does not benefit patients or doctors unless these key issues are addressed.
Doctors do not strike but with a heavy heart – but the NHS, our nation’s greatest triumph, must be protected. It has indiscriminately touched all of our lives, and together, we can ensure it will continue to do so, hopefully for many more years to come.
Image from: http://www.theguardian.com/healthcare-network/2015/sep/29/junior-doctors-strike-support-poll-contract-nhs