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November 30, 2015

Private Eye Medicine Balls 1344
Filed under: Private Eye — Dr. Phil @ 12:57 pm

Junior doctors speak up

As health secretary Jeremy Hunt and the BMA prepare to do battle over the junior doctors’ contract, spare a thought for the doctors themselves, many of whom aren’t even members of the BMA. Many have shown great courage to speak up in person, not anonymously. They are also numerate and understand the scientific method, two qualities that appear to have eluded the health secretary of late. Jeremy Hunt is relying on his manifesto mandate (i.e. the votes of 24% of the eligible electorate) to enforce whatever he means by a seven day NHS, supported by a paper in the British Medical Journal in September entitled ‘Increased mortality associated with weekend hospital admission: a case for expanded seven day services?’ Note the question mark.

The article reported an analysis of 30 day mortality after admission to hospitals in England and found an excess number of deaths among patients admitted at weekends. It found that 11?000 more people die each year within 30 days of admission to hospital on Friday, Saturday, Sunday, or Monday than on other days of the week. So not just weekends, but Fridays and Mondays too. It was not able to determine why this occurred or whether any of the excess deaths could have been avoided.

The paper ‘arose from a request by Bruce Keogh’, the medical director from NHS England, and he also appears as one of the authors. So the most senior doctor in NHS England has ordered and co-authored a paper that is politically very convenient for Jeremy Hunt, who promptly spun it to support his threat of imposition of new contracts for junior doctors and consultants. This prompted BMJ editor Fiona Godlee to write to Hunt ‘to register my concern about the way in which you have publicly misrepresented an academic article’ In essence, Hunt’s proposition that the excess deaths would be reduced if, say, more doctors worked at weekends is entirely unsupported by evidence. It may be that patients admitted between Friday and Monday are simply sicker and therefore more likely to die.

Even if more doctors would help reduce mortality, they need to be supported by other hospital services and more social care, and noone numerate believes this can be done in the context of £22 billion efficiency savings. Hunt’s offer to junior doctors is cost neutral, which can only mean that more staff at weekends would leave less staffing on weekdays. And having boldly promised that no junior doctor would lose out, Hunt had to backtrack and admit the 500 junior doctors currently working the longest hours in the critical care specialties will lose out substantially. The ‘salary guarantee’ for others is only until 2019 and as just about all NHS contracts at present have built in savings year on year, it’s unlikely that doctors salaries will be immune in the longer term.

Bruce Keogh, who had angry letters from a thousand doctors, has now distanced himself from Hunt. “We were very clear that it is not possible to ascertain the extent to which these excess deaths may be preventable.’” Hunt has not lifted the threat of enforcement of a new contract on junior doctors and the BMA’s ballot for strike action has gone ahead. It’s a high risk strategy on both sides but Hunt may secretly hope the BMA backs itself into a corner to distract from the wider ills of the NHS. The service is on its knees not because of the way doctors work but because, as the OECD pointed out last week, it has had zero growth in health spending since 2009. The UK is in the bottom third of OECD countries in five-year relative survival for colorectal cancer, breast cancer and cervical cancer, and survival after hospital admission for a heart attack or stroke is also worse than in many OECD countries. Stretching the same number of doctors over 7 days probably won’t solve this.

Junior doctors are the smoke alarms of the NHS. They know the service is seriously under-resourced, their stress and debt levels are high and they are anxious, angry and unhappy at a health secretary who has lost their trust and is now trying to threaten them into submission. Above all, they need a work life balance to allow them to rest, relax and recover. Many will end up seeking this abroad. Others will carry on working unpaid illegal hours to cover vacancies, sick colleagues and even sicker patients until they burn out. No-one avoids death in the end. But as the Mid Staffs scandal proved, the deaths in a service cut to the bone can be deeply unpleasant and scar those who witness them for life.

MD’s book, Staying Alive – How to Get the Best from the NHS – is available here