Over to you, Dave
As the BMA announced more industrial action and a judicial review into the government’s contract imposition on junior doctors, the world’s foremost patient safety expert and Cameron’s former health tsar was blunt about what needs to happen next. ‘I think the government should apologise. You cannot achieve excellence in combat with your future workforce, it makes no sense at all.’ He also warned it may be “impossible” for the NHS to tackle the issue given the current level of funding. No Western democracy can provide a high quality, safely staffed service at less than 8% of GDP. The NHS gets 6.8% and needs the equivalent of 3p on income tax to recover. It is currently missing all its targets, has huge gaps in service provision and work rotas, is underfunded this year alone to the tune of £3 billion and is bullying its staff into unsafe working conditions.
Junior doctors asked for contract renegotiations four years ago because they felt their current rotas were unsafe, with large rota gaps in the most stressful specialties that provide urgent and emergency care – ITU, A&E, acute medicine and surgery, anaesthetics, obstetrics, paediatrics. The NHS already has fewer doctors per head of the population than most others, and the working life is so unremitting it struggles to retain them, and many opt to work part time to survive. Doctors are fortunate to have relatively well paid jobs and high job security, but the toll of full time NHS work on their mental health is alarming, and tired doctors make mistakes.
Health secretary Jeremy Hunt is right to be concerned about variations in mortality rates in the NHS, but wrong to jump to simplistic conclusions and try to extend cover over the weekend without committing funding and staffing to it. 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. Hunt is trying to do it ‘cost neutral’ with existing staff numbers, and some rotas have unsurprisingly got worse, not better.
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 (i.e. to stretch five days’ worth of doctors over seven), the government has produced rotas that simply 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.’
At the very least, the new rotas need to be properly trialled (Eye last) 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 NAO 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.’ 1
Hunt claims the NHS must learn from the airline industry, but no pilot would be allowed to work these rotas, and no airline would ignore the safety concerns of 55,000 pilots. When Hunt announced he would impose the new rotas, he promised that ‘no doctor would be rostered consecutive weekends.’ And yet the rota for ‘typical ITU training’ has two consecutive weekends twice and three consecutive weekends once. Other rotas – particularly for the most stressful jobs with busy night cover are equally unappetising. The new rotas will almost certainly make recruitment and retention worse, and the caps on locum fees may meant gaps don’t get filled at all leaving over-worked consultants to provide the cover. No wonder they are supporting their junior colleagues so enthusiastically. And yet all the junior doctors MD has spoken to would graciously accept a government apology for imposition, and restart negotiations that are properly resourced. Hunt may be a busted flush, but Cameron will not want his legacy to be a busted NHS. Over to you Dave.
If Cameron, Hunt and the rest of the government refuse to accept the guidance of the world’s foremost patient safety experts to publish the contract in full, call a pause to imposition and allow independent analysis then the only alternative to more industrial action is to try for judicial review. Inspirational junior doctors are raising funds for a legal review of the imposed contract, and I’m supporting them. An imposed, untested contract could seriously harm patients. We all need to know if the government’s actions are safe and legal.