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March 9, 2016

The junior doctors dispute explained simply but in detail…
Filed under: Private Eye — Dr. Phil @ 7:41 am

The junior doctors dispute explained simply and in context…

It is not possible to explore the Terms and Conditions of the proposed contract in detail because they have not been published yet and may still not have been finalised. The announcement of the imposition of a contract that has yet to be finalised and can’t be scrutinised by the junior doctors who are be imposed upon has been highly counterproductive. Irrespective of the content of the final contract, I believe imposition is wholly wrong.

This is not a dispute about Saturday pay, it’s about safe staffing. Safe staffing requires both safe rotas and a safe number of staff to fill them.

Junior doctors have not asked for more money, but for a better, safer NHS. However, a better safer NHS will cost us more because it needs more staff at all levels and occupations The government’s manifesto promised ‘a truly 7 day NHS… to ensure you can see a GP and get the hospital care you need 7 days a week by 2020.’

Urgent NHS care is already available 24/7, but this commits the NHS to providing the routine care you need 7 days a week, in general practice and in hospital. Many GPs already offer routine and emergency appointments on Saturday mornings. The government has promised you will able to see a GP 12 hours a day, every day, 8am – 8pm, by 2020. We need at least 5000 more full time GPs just to keep the current service safe.

Some hospitals do routine work on Saturdays but nearly all routine hospital work is done on Monday to Friday. To extend this to a ‘truly 7 day service’ would require an increase in routine work of around 40%, to be done on Saturdays and Sundays

This extra work for GP practices and hospital staff over weekends can either be done by training and employing more staff. Or by spreading the existing staff more thinly.

Extending services over 7 days without employing extra staff could make the NHS less safe, not more.

The junior doctors’ contract offer is ‘cost neutral’ – no more money is available to employ more staff. So existing staff would have to be spread more thinly. Wards would be less well staffed during the week to move more staff to the weekends. This could make the NHS less safe for patients, not more.

The government’s manifesto also promised: ‘We will continue to ensure we have enough doctors, nurses and other staff to meet patients’ needs.’ However, the government halted and then tried to prevent the publication of vital work by NICE to determine safe staffing levels, developed after the Mid Staffs scandal to try to prevent future scandals where there are dangerously low levels of staff. This withholding of crucial evidence is seriously at odds with the government’s manifesto commitment to make the NHS the safest health service in the world. The only plausible explanation is that they do not wish to commit the money to funding the safe staffing levels needed.

Tax payers should be asked if they wish to pay more into the NHS to fund safe staffing.

The NHS currently has dangerously low levels of staff and large numbers of vacancies. A recent BBC Freedom of Information request shows that on 1 December 2015, the NHS in England, Wales and Northern Ireland had more than 23,443 nursing vacancies – equivalent to 9% of the workforce. For doctors, the number of vacancies was 4,669. In England and Wales, there were 1,265 vacancies for registered nurses in emergency departments – about 11% of the total. For consultants in emergency medicine there were 243 vacancies – again 11% of the total. Paediatric consultants – specialists in the care of babies, children and young people – were also hard to recruit, with 221 vacancies – about 7% of the total.

For junior doctors, there are already dangerous gaps in the rotas for many specialties every day of the week because there simply aren’t enough doctors to fill them. Putting a cap on locum fees has made the rota gaps worse. Extending cover safely over the weekends can only happen with more doctors, not by spreading the already exhausted workforce more thinly.

Doctors are expensive to train and employ, so this is also a question for us. How much are we prepared to put into the NHS to staff it safely?

The current funding cannot cope with the current demand on services as we live longer, and survive more illnesses. We do not have enough doctors, nurses and staff in most other professions at present.

Staff in hospitals which have large numbers of vacancies already work well above their contracted hours, often for no pay. Some are bullied into doing so. There needs to be a robust and proven mechanism of preventing overwork and exploitation because tired NHS staff make mistakes that can harm and kill patients. The new junior doctors’ contract does not have this.

The number of deaths in hospitals does vary during the week but we do not yet know why. It may well be that introducing safe staffing levels would reduce some of the avoidable deaths. However, this can only be safely done by employing more staff, not by spreading the existing staff more thinly.

A leaked report from the Department of Health has suggested that equal NHS cover over 7 days would need 7,000 more nursing and ancillary staff, and an extra 1600 consultants and 2400 junior doctors, and would cost £900 million. And yet the junior doctors contract is cost neutral.

Shift systems harm both mental and physical health, and where they’re unavoidable, such as in the NHS, a great deal of care and expertise needs to be put into designing them to ensure minimal sleep disruption, adequate recovery time and a fair work life balance. Junior doctors have the additional requirement that they are doctors in training, and so need protected training time alongside providing a safe service.

In attempting to increase cover at weekends without increasing overall staffing levels, NHS Employers has produced sample rotas that probably aren’t safe for doctors or patients. They would appear they have been rushed through without the essential input of sleep and fatigue specialists. As Dr Michael Farquar, a Consultant in Paediatric Sleep Medicine, wrote in the Independent: ‘I note with dismay the rotas that include frequent rapid cycling between long (13 hour) day and night shifts. These ill-considered proposals run a risk of creating increasingly jet-lagged doctors, more likely to make mistakes while carrying out tasks which require high levels of attention and judgement. I urge NHS employers to reconsider, taking into view evidence collated by the Health and Safety Executive and the Royal College of Physicians.

The new junior doctor work rotas need to be properly trialled, to see what effect they have on attention, judgement and reaction time in a very stressed NHS frontline environment. Written evidence by the Cass Business School for the National Audit Office expresses serious concerns about stress and fatigue of junior doctors on shift work and recommends ‘a rigorous feasibility study’ of the new contract prior to implementation to ensure safety.’

The new junior doctors contract would appear to reward doctors in specialties with little or no on-call duty, but may penalise those in specialties with lots of emergency duty. These are precisely the doctors we need to train to improve 24/7 urgent and emergency care in the NHS and the fear is that these emergency specialties will become less attractive to doctors.

Doctors have a professional duty to protect patients and to speak up if they believe care is not safe. Most doctors believe the new contract for junior doctors could make the NHS less safe for patients, which is why so many consultants and GPs are supporting their junior colleagues. Because the government has announced it will be imposed, most junior doctors believe that the only option is to take industrial action. This has to be balanced against a doctor’s professional duty not to harm patients. It’s an extremely difficult decision to make, and many doctors have been reduced to tears having to make it.

My greatest concern is for the mental health of NHS staff. Many are struggling to provide a safe service in very difficult circumstances and levels or work related stress, anxiety and depression are very high. It is hard to imagine how the imposition of a contract that many doctors believe is not safe or fair will improve their morale and mental health. Rather, imposition could have a disastrous effect on morale, recruitment and retention of staff.

There is no urgent need for a new junior doctors’ contract, and Wales, Scotland and Northern Ireland have no plans to introduce any such changes. If it is imposed in England, industrial action could be prolonged and a whole generation of doctors may be alienated and demotivated. Many may leave the NHS entirely, at huge cost to the taxpayer and to patients. Other bright students may decide not to enter medicine at all.

To repeat, the new contract has not even been published in full, and the final terms and conditions are still being decided. To announce imposition of an unwritten contract so far in advance of publication has been hugely divisive. Sample rotas and pay calculators have been rushed out, found to contain significant errors and then withdrawn. Such an important contract cannot be rushed through and made up on the hoof just to meet a political deadline. It’s far more important to slow down, think clearly and get it right.

A far more sensible and safe option would be for both sides to call a pause both to imposition and to industrial action. This would allow independent analysis of safe staffing levels and what seven-day services can safely be delivered with the staff we currently have. It might also identify the extra funding we would need to put into the NHS to provide an extended seven day service, if indeed that is the best use of NHS money. It makes no sense for a government that wants to improve the NHS to go to war with the workforce. Particularly when the workforce is kind, committed and able to come up with many of the solutions the NHS needs if only it were included and involved. The views of patients, carers and tax payers must also be heard. Any solution has to be guided by compassion, collaboration, evidence and sustainable funding. Any final proposed contract – and the new rota patterns – have to be calmly and rigorously tested, costed and safely staffed. And it has to be agreed, not imposed. Negotiations must restart as soon as possible.

Declaration of Interests

I am an NHS doctor and patient, but not a member of the BMA or any political party. As a junior doctor, I was an active campaigner for a better, safer NHS from 1987-1992. I was invited to become a Vice President of the Patients Association for my role in uncovering the Bristol heart scandal in 1992. 24 years later we still haven’t safely reorganised child heart surgery in the UK, for all manner of complex political and professional reasons. I have campaigned for many years for the rights of NHS whistle-blowers, and although this current conflict may take a while to resolve frontline staff, patients and carers must be encouraged to speak up and express their safety concerns.

Any errors in this article are entirely mine, for which I apologise. Please correct them, join and improve the debate. Please do not impose.

  • Fiona Weir

    Hi Phil,
    This is a great blog – the clearest and most comprehensive explanation I have seen so far. Thank you.
    Where you give the vacancy figures across the NHS, you generally give both number and percentage (for example “the NHS… had more than 23,443 nursing vacancies – equivalent to 9% of the workforce”). You only give the number for doctors, 4,669; what percentage is this, please?
    Thanks, Fiona

  • Ros

    My daughter’s multiple disabilities were caused when a doctor at the end of a 72 hour shift, during which he had never had more than 2 consecutive hours’ sleep, forgot to score off her drug sheet a drug that had been seen to have a seriously adverse effect in depressing her breathing. The resultant prolonged apnoeic episodes left her with quadriplegic cerebral palsy and severe autism. That’s why I support the junior doctors in their opposition to Jeremy Hunt taking us back to those dark ages.

  • David Potter

    I think Dennis Skinner has a good grip on this subject as a long standing openly spoken MP:

    Dennis Skinner gives J. Hunt HELL. J. Hunt replies with more half truths.?: … … …

  • historydoctor

    “Other bright students may decide not to enter medicine at all.”

    It’s already started. The number of applications to medical schools actually fell last year, and that’s very unusual.

  • Jane Patricia Fish

    Thank you.
    This is the most reasoned, in depth analysis that clearly states the facts and suggests a way forward. Why has this government take on the Junior Doctors in this way? And student nurse and AHP bursaries going from 2017…………. Very disappointed to see no coverage in the Press of the 7000 Doctors demonstrating in London yesterday. Both sides need to get back to the negotiating table.
    Jane <

  • Mac Obermaier

    Like most people I have been grateful that there is a medical profession and would happily support any just claim they or others treated unfairly may have. My problem with this article is that it makes sweeping statements that readers need to make assumptions about and I make no apologies for a preference for facts to work with. In my time I have worked at home and abroad as a soldier, welder, miner and in management of plant hire, I still work in retail though retired as pensions can be and are tweaked by politicians so I have no love of them. Equally I am no stranger to working long hours in trying circumstances where the public are clueless about realities of them and are not in the least concerned or grateful so I don’t vote in sympathy with sob stories. The following points interest me if you have a moment.
    Why now or if subsequently you had the required manning levels and the workload is the same are more staff required ?
    Not the doctors issue but why isn’t the use of private professionals banned? Could they all be in full employment without the NHS and if not why are they paid premium rates when called upon? Or is the system engineered?
    Why are “facts” as presented by junior doctors as biased as those of politicians, do they really all work excruciatingly long hours every day? What is the actual average? How much is contractual?
    Why are the public expected to believe either side that the issue is all about safety, call me cynical but life teaches that money talks 95% of the time.. But if so how can lack of cover at weekends be reasonable? It certainly isn’t in retail.
    I assume doctors know what they are getting in to when starting out in their careers and judging by those operating locally, they all seem to retire much earlier than their 3 score and 10 and in financial circumstances that many would give their right arm for.
    I have to say that while keeping an open mind and wishing to see the end of the stalemate I feel that doctors are currently exploiting the public sympathy. Not an infinite commodity.

    • Hari

      I am a jobbing junior doctor, so not necessarily au fait with all the facts, but hope I can provide some insight from the shop floor.

      1. The workload for healthcare has increased exponentially with scientific advances. I am a cardiologist. In my 15-year-career, we have moved from treating heart attacks with “thrombolysis” (a potent clot-busting drug that takes 1 minute to prescribe and a nurse 5 minutes to administer) to performing emergency angiography, angioplasty and stenting (an invasive procedure that takes 1-3hours, 1-2 doctors, 1 nurse, 1 radiographer and 1 physiologist). Before I trained, heart attacks were treated with aspirin and bed rest. Health staffing has increased over the years, but not at an adequate rate to match the demands.

      2. I don’t really understand your question here. Do you want to ban private healthcare? Almost no junior doctors ever have any meaningful interaction with private healthcare in their career.

      3. The term junior doctors covers over 50,000 individuals. We do not work the same job. The issue is the new contract rewards the hardest-working the least. I have no idea what the average hours worked are. All junior doctors have to currently monitor their hours over a 2 week period every 6 months. Each time, we are asked to decide whether our “extra” hours over and above the 48 most are contracted for are “voluntary” (and therefore unreported). Any work that has a positive impact on career development would often be considered to fall into this “voluntary” category. By reporting “compulsory” hours above 48, the ratio of service provision (i.e. care that would otherwise not be delivered at all) to career development (i.e. time that is potentially beneficial to doctors training, but may still free up consultants to deliver additional care to patients) is increased by hospital management to ensure that hours remain below 48 and therefore not prompt a pay rise while care is still delivered safely to patients. I think it important to remember junior doctors are actually consultants (and to a lesser extent, GPs) in training, so reducing career-development time has a long term negative impact on patient care in the NHS. On a personal note, I have to go to work on my annual leave days for adequate career development in the current state of the NHS, in order to ensure I am appropriately trained as a consultant-in-waiting.

      4. There is no “lack of cover” on weekends. There is a fully-staffed (allowing for staff vacancies) emergency medical service on weekends. What that means is that you may be inconvenienced by having to wait until Monday for that minor illness to be dealt with, but that if you are actually sick, you will receive the necessary care. Convenience versus clinical safety. The retail industry focus is on convenience for shoppers on weekends. NHS staff are generally not against patient convenience, but would always prioritise clinical care. Delivery of a convenient service requires more staff, which in turn costs more. It is not mathematically possible to spread the same workforce at the same density across an extra 2 days.

      While none of this directly answers your request for facts, I hope it does at least go some way to explaining the situation.

  • CharlieFDevon

    Thank you Phil! I am a furious GP and I fully agree with your analysis. I just wanted to add that the leaked DoH document also said that the number of additional junior doctors needed to make this new contract work is IN ADDITION to the number of currently unfilled vacancies which I think stand at about 6000 of 53000? So in fact about 10000 more junior doctors would be needed to make the contract work for a truly 7 day routine NHS (and there is no Western Health Service in the world that provide a truly 7/7 routine service due to excessive costs and lack of need)- not counting all the other vital staff. Hunt and the rest of the Tories are evil narcissists

  • Col Oaten

    Thanks for the clear and concise explanation. The Nasty Party are “preparing” the NHS for private companies to come flooding in after TTIP and make a killing. It is as simple as that. Would I believe/back a politician over a doctor? Not a chance. All the staff who work in the NHS get my backing and full support. This government is truly a bunch of traitors. Hang the lot of them.

  • Roger Stevenson

    Thios is a cogent and well resoned argument. As someone living in Wales, where the NHS is more highly regarded by government, I am wondering whether this dispute will mean more junior doctors moving here or to Scotland. That would be an interesting statistic to see.

    • Libertê Harries

      I’ve thought that………

  • Adam Ansel

    The BMA has been negotiating with the Government for three years. There have been three independent processes to broker a settlement and 75 negotiation meetings. There have so far been 73 concessions made by the Government towards the BMA’s position. Yet the union says it will only drop the strike if it is allowed to resume its obstructive tactics.

    Part of the reason that we are in this mess, with medical contracts not fit for purpose, is because Labour ministers previously caved in to such demands for extra pay and reduced out-of-hours responsibilities. This happened after the BMA declared war over attempts to reform the consultant contract in 2003, with Labour handing the consultants a 27 per cent pay rise, along with the right for the first time to opt out of weekend work….
    Labour also oversaw the 2004 GP contract, which increased salaries by 50 per cent; meanwhile, 90 per cent of GPs took up an offer to allow them for the first time to opt out of providing out-of-hours care. BMA negotiators later admitted that they could not believe their luck. An independent report found that 43 per cent of the extra funding that Labour poured into the NHS went on higher pay and prices, largely because of these pay deals.

  • Steve Powell

    “It makes no sense for a government that wants to improve the NHS to go to war with the workforce.”

    This is very true; however, it makes perfect sense if the government’s long-term aim is to cripple the NHS so as to be able to scrap it altogether. This looks very much like a campaign of “constructive dismissal” for the National Health Service. It reminds me of strategies currently being used in the State School system.

    All that has to happen is that the NHS becomes ineffective and it will be deemed “unaffordable” to fix, so the only “sensible” alternative will be to “ask the private sector” to help. Mandatory health insurance policies will follow, with the weakest going to the wall and the profits going to the government’s friends.

  • Slithy

    “It makes no sense for a government that wants to improve the NHS”, but of course, the Tories don’t want to IMPROVE the NHS, they want to PRIVATISE it!