“In the good old days; you were poor, you got ill…and you died.”

In the ancient world, there were three types of satire. That which made light of the difficulties of life; that which openly attacked the monstrous incompetence of public figures; and that which attacked the mental models which led them to act in cruel and prejudicial ways. Nowadays constructing political satire requires a huge amount of effort and subtlety – why? Because the boundaries between satire – parody – and reality have become terrifyingly blurred.

This snippet is from the brilliant ‘The New Statesman’ (see more here) which aired in the UK between 1987 and 1992. The most disturbing thing about watching this little speech in 2016, is that what passed for a ridiculous parody of Conservatism in the 1980s, is now quite an accurate  depiction of the behaviour, attitudes and even appearance of our incumbent politicians. How easy is it to imagine Jeremy Hunt bleating with a similar level incredulity in response to people resisting his efforts to destroy the NHS?

“I like curry, but now that we’ve got the recipe, is there really any need for them to stay?”

Still not convinced that our politicians, buoyed by the right wing press and unrestrained by any real accountability, are morphing into horrible parodies of themselves? Try this snippet on immigration, from Rowan Atkinson’s ‘Not the 9 O’Clock News’ sketch from 1979.

 

And here’s the real-life George Osborne……

Finally, I’ve always wondered where that old story came from, you know the one about how overspending on the NHS, The Police, Social Security etc during the last Labour government caused a Global Financial Meltdown. You know – that story they tell over and over and over again to justify Austerity? What’s that?  It’s based on empirical observation, careful reasoning and expert analysis you say? Not exactly – it’s actually just rehashed from this  ‘Not the 9 O’Clock News’ snippet circa’ 1980.

 

So herein lies the problem. Maybe when we see and hear politicians nowadays, our brains subconsciously think that what we are experiencing is satire and parody. Perhaps, as a result, our outrage and horror – which should be spurring us into action – are instead being transmuted into amusement.

 

Allowing the CQC to regulate Junior Doctors’ hours is a Trojan Horse for the NHS

One of the main concerns that Junior Doctors have raised over their new contract relates to the removal of the banding system which acts as a safeguard against being forced to work an excessive number of hours. Part of the reason the banding system exists is to prevent patients being seen and treated by exhausted doctors. There has been a degree of muted welcome to the recent suggestion that the CQC (Care Quality Commission) could take over the role of monitoring doctor’s hours if the banding system is abolished. The possibility of the CQC being involved in policing doctor’s hours is extremely concerning and it is not just doctors who will be put at risk, but the NHS as a whole.

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Patient Safety : The Narrow View

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To construct a truly comprehensive picture of  the conditions which affect patient safety, say for example, in a specific hospital, you have to consider the situation from a very broad perspective. This includes looking at the ways in which governmental policy with regards to health and social care funding and staffing regulations can affect a hospitals’ ability to deliver safe care. Sadly, the CQC is not afforded the luxury of such a broad perspective. Instead, it is simply asked to report on what it sees, namely; is this unit safe / effective / caring?  It is not within its mandate to analyse or comment on the broader determinants of why the system in question might be unable to deliver safe care. Take the recent case of Addenbrookes for example. The CQC was compelled through its observations that the hospital was understaffed, bed-blocked and in significant debt to downgrade it from its highest rating (awarded just over a year ago) and place the unit into its special measures process. A broader view of the constraints upon Addenbrookes would have identified the council cuts in social care that were preventing patients leaving hospital, in addition to the restrictions on nurse recruitment which were preventing the unit from achieving safe staffing levels. Such observations have led some to suggest that the CQC is being used by the DOH to punish trusts for negative safety outcomes that are actually the result of the governments gradual erosion of the health and social care infrastructure that supports the NHS.

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The Trojan Horse

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The recent document from NHS employers outlining the revised junior doctor contract proposals suggests that the CQC should have a role in the ‘robust external scrutiny’ of doctors’ hours and that ‘there will be serious consequences for trusts and their boards who receive low inspection ratings for safe staff requirements’. At the same time, the NHS England Board paper entitled ‘NHS Services, Seven Days a Week’ which outlines the program for implementation of seven day services states ‘the CQC should be asked to consider how the implementation of the clinical standards [for seven day working] might be reflected in judgements / ratings’.  The government is therefore proposing that trusts be judged against two irreconcilable standards. Fristly, the new contract suggests a reduction in the number of hours doctors are legally allowed to work each week and if trusts violate this, they will be penalised by the CQC. They are also proposing that failure to implement 7-day working be penalised by the CQC. So how will trusts get the same number of doctors to provide a comprehensive, 7-day service, whilst working less hours overall? Either trusts will have to violate the junior doctor contract restrictions with rotas that have excess hours and get penalised by the CQC or they will fail to implement 7 day working and then get penalised by the CQC – Catch 22.

But why would the government construct this Trojan horse style arrangement which could destabilise the NHS from within? At the risk of sounding like a broken record, I refer you once again to ‘Direct Democracy’ by Jeremy Hunt et al –

Page 74 “The problem with the NHS is not one of resources. Rather that it is a centrally run, state monopoly designed over half a century ago.”

What we are seeing is the slow destruction of the NHS, based on the ideology that healthcare should not be run by the state.  Bevan predicted this 67 years ago when he wrote, regarding the Conservative attitude towards the NHS that:

‘If the Service could be killed they wouldn’t mind, but they would wish it done more stealthily and in such a fashion that they would appear not to have the responsibility.’

from ‘In Place of Fear’ by Aneurin Bevan

One of my colleagues recently commented that the NHS is the greatest gift that Britain has ever bestowed upon herself – I could not agree more. So it is in defence of the NHS that I will be voting #yesyes and if and when the time comes, joining my colleagues and friends on the picket lines.

A brief history of the UK Junior Doctors’ Contract Debacle

INTRODUCTION

The dispute regarding junior doctors’ contracts stretches as far back as 2012.  At that time, the Department of Health (DOH) decided that the terms and conditions of employment for the 53,000 junior doctors in England needed to be revised for two main reasons.  Firstly, the contracts had not been updated since the late 1990s.  Secondly, the idea of a 7-day NHS was being suggested and the DOH proposed a major reconfiguration of junior doctors’ work patterns to fit with this new model.  Official negotiations between the British Medical Association (BMA) and the DOH began in October 2013, but after almost 2 years, no consensus was reached.  In August 2015, the Junior Doctor’s Committee of the BMA decided not to re-enter negotiations and accused the government of taking a ‘heavy-handed approach’.  Ministers then stated that they intended to impose the new contract on all junior doctors from August 2016 – triggering the current wave of protests and the proposed industrial action.

Although the issues surrounding the fine details of the contract are complex, junior doctors’ concerns boil down to two major objections.  Firstly, we are very concerned that the proposed contract is NOT SAFE and will put patients at significant risk by stretching the resources of an already strained system beyond breaking point.  Secondly, we are distraught over the fact that the proposed contract is also NOT FAIR and will decimate morale and working conditions through for example, the removal of remuneration guarantees and safety restrictions relating to out-of-hours work.

The official declaration from the BMA states:

“We urge the government not to impose a contract that is unsafe and unfair. We will resist a contract that is bad for patients, bad for junior doctors and bad for the NHS.”

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WHY THE PROPOSALS ARE NOT SAFE

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1. The proposals are based upon the misinterpretation of mortality statistics

 When explaining the rationale behind a 7-day NHS, Jeremy Hunt most often quotes a study from 2012 by Freemantle and colleagues published in the Journal of the Royal Society of Medicine.  This study suggests that people admitted to hospital at the weekend are at increased risk of dying in the 30 days following their admission.  Based on statistical modelling, the paper suggests that there may be around 11,000 excess deaths due to what they term ‘the weekend effect’.  A direct quote from the paper’s conclusion states:

“It may be that reorganized services providing 7-day access to all aspects of care could improve outcomes for higher risk patients currently admitted at the weekend.  However, the economics for such a change need further evaluation to ensure that such reorganization represents an efficient use of scarce resources.”

Essentially, the conclusion is that extending ‘all aspects of care’ – which would include elements such as laboratory facilities; imaging services; allied health professionals etc might reduce some of these deaths.  Jeremy Hunt however has repeatedly asserted, as in the quote below, that increasing the number of doctors at weekends is the key to reducing this excess mortality. There is no evidence that this measure alone will address the issue of excess mortality and there are no plans for an associated expansion of ‘all aspects of care’.

“What we do need to change are the excessive overtime rates that are paid at weekends that give hospitals a disincentive to roster as many junior doctors as they need at the weekend which leads to those 11,000 excess deaths.”

 Jeremy Hunt, Questions in the House of Commons 13^th October 2015

We have highlighted over and over again through campaigns such as #iminworkjeremy that there is no change in the number of junior doctors staffing acute services at the weekend.  The BMA, shadow health secretary, DOH and members of the conservative party, have all tried to gain an understanding during negotiations as to why Mr. Hunt is misrepresenting the data and focussing excessively on junior doctors, but answers have not been forthcoming.

“I am unclear how a new junior doctor contract that will cut the pay of doctors entering GP training, cut the pay of psychiatry registrars…..and cut the pay of A&E doctors, will help deliver a seven-day service.”

 Dan Poulter, Conservative MP and Parliamentary Under Secretary of State in Department of Health until May 2015.  Writing in ‘The Guardian’ 4^th October 2015

2. The DDRB proposals will remove regulations on unsafe working patterns

Based on this opaque and confusing  interpretation of the data, the government asked the DDRB (Doctors’ and Dentists’ Remuneration Review Body) to consider all ‘evidence’ relating to contract negotiations for junior doctors and consultants in England. The DDRB are a group comprised of government selected reviewers with no background in healthcare. They were asked to make recommendations by July 2015.  

One of the main recommendations that emerged in the DDRB report, which is in keeping with Mr Hunt’s misinterpretation of the evidence, is for a change in the definition of what constitutes out-of-hours’ work for a junior doctor.  The aim of these changes is to allow hospitals to rota junior doctors to work extra, unregulated, unsocial hours without an increase in pay or rest periods.  At the moment, junior doctors are paid ‘standard’ time during normal working hours, which are defined as 7am-7pm Monday to Friday.  In the proposed amendments, ‘standard’ time will be extended from 60 hours to 90 hours per week and stretch up to 10pm every night of the week apart from Sunday.  Essentially, this will classify antisocial hours such as 9pm on a Saturday within the same bracket as say 2pm on a Wednesday.

Crucially, the current system also has built in safeguards to prevent employers from forcing doctors to work excessive hours and to ensure that they receive adequate breaks.  These safeguards were introduced, in large part as patient safety measures so that people were not being seen and treated by doctors who were exhausted and overworked.  There is no alternative system proposed either within the DDRB report or by the DOH, to protect junior doctors from unsafe working conditions or to protect patients from the consequences of these.  We are gravely concerned that this loss of safeguards may see a return to the ‘bad old days’ were junior doctors worked for 100+ hours per week and patients suffered as a result.

“If you assume that we’re just about coping in the five days that we’re working now, you will need another two days’ worth [of doctors]. You’re asking for two days’ more work out of people.”

Jane Dacre, President of the Royal College of Physicians, ‘The Guardian’ 13^th October 2015

3. Hunt’s proposals are ‘Rash and Misleading’

In September 2015, Freemantle and colleagues published a follow-up to their original weekend mortality study in the British Medical Journal.  The authors do not explicitly state that the new study is partially a response to Mr. Hunt’s misuse of their statistics, but contained within the paper are a number of thinly veiled rebuttals of Mr. Hunt’s misinterpretations:

With regards to the excess weekend mortality that Mr. Hunt is constantly referring to:

“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” 

 With regards to the measures that may reduce the excess mortality:

“Appropriate support services in hospitals are usually reduced from Late Friday through the weekend, leading to disruption on Monday morning.  This could go some way towards explaining our findings of a ‘weekend effect’”.

Mr. Hunt has repeatedly stated, with great certainty, that the deaths can be avoided by increased antisocial hours work by junior doctors – a rash and misleading assertion that is not grounded in evidence. In recent days, the editor of the British Medical Journal has written to Mr. Hunt personally to express her concerns about his misuse of her journal’s published data.

“I am writing to register my concern about the way in which you have publicly misrepresented an academic article published in The BMJ.”

“What [the paper] does not do is apportion any cause for [the excess mortality], nor does it take a view on what proportion of those deaths might be avoidable,”

 From Fiona Godlee’s Letter to Jeremy Hunt 21^st October 2015

4. The NHS cannot afford a 7-day service in the current funding climate

 In discussing the economics of a 7-day comprehensive service, Freemantle and colleagues state:

“The economics for such a change need further evaluation to ensure that such reorganization represents an efficient use of scarce resources.”

 The NHS is at present facing a funding crisis.  There is already a £930 million deficit from just the first 3 months of this financial year, with a likely £2 billion deficit predicted by the end of the financial year.  Since its inception, up until 2010, the NHS received a 4% real terms increase in funding year on year.  This allowed the service to expand and keep up with the proliferation of complex medical interventions needed to treat a growing and ageing population afflicted by increasingly complex medical problems.  Since 2010, the average annual increase in funding has been just 0.4%.  This is in spite of vast bodies of international evidence stating that during times of economic austerity, sustained health expenditure is crucial, both to prevent excess mortality and to support economic growth by maintaining the health of the workforce.

A true 7-day NHS where ‘all aspects of care’ are expanded is currently well beyond the realms of affordability, unless the current government allocates a significant amount of financial resources to the NHS.  The excessive focus on junior doctors has been a major distractor from this fundamental issue. 

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WHY THE PROPOSALS ARE NOT FAIR

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1. Extension of ‘standard time’ and ending banding payments will see junior doctors receiving up to 30% less pay

Junior doctors routinely work outside of the current ‘standard time’ and are happy to do so to provide their patients with high quality care around the clock.  Currently, if junior doctors work outside these hours they receive a pay premium reflecting the impact of unsocial hours on personal and family life.  The changes to routine working hours will result in junior doctors working what are widely classified as antisocial hours, with no pay premium.  Evenings and weekends are precious opportunities to spend time with friends and family and we feel that it is only fair that pay during those times reflects this.

Furthermore, the DDRB have proposed that the current ‘banding system’, which provides junior doctors with pay supplements based on an overall assessment of the length and unsocial timings of their duties, will be removed and with them safeguards (discussed above) to prevent junior doctors working excessive hours.  A simpler alternative to the banding system was broadly supported by junior doctors.  However, due to the extension of ‘standard time’ the current proposals will disproportionately impact pay in specialties that have particularly heavy out-of-hours commitments such as Anaesthetics and A&E. We are very concerned that this will further dis-incentivise people from training in these specialities, some of which are already significantly under-staffed.    

By extending ‘standard time’ and removing the ‘banding system’, some junior doctors stand to lose up to 30% of their salary, effectively overnight. 

2. Pay progression will disadvantage junior doctors who take time out due to sickness, maternity leave or to undertake research

Under the current contract, junior doctors’ pay increases every year in recognition of experience gained.  The new contract will remove this, and accumulated pay progressions. Pay will only rise upon progression to higher stages of training (there is no clear plan from the DOH as to how exactly this will work). This change will disadvantage those who take time out of training, for example because of maternity leave or sickness, or to train less-than-full-time. Such doctors may lose years of accumulated pay and take significantly longer to progress up the pay scales. This is a change which would particularly affect women.  It would also negatively impact those taking time out to undertake research.  Pay progression should recognise the increase in valuable experience that comes with spending time in training, working and researching.  No one should be put off training in medicine because of their gender or personal circumstances. 

“Removal of annual pay progression and its replacement with pay increases only at points of responsibility is potentially discriminatory for less than full time trainees as they will be exposed to a greater financial risk because of the delay they will inevitably experience in reaching their responsibility thresholds.”

 Extract from an Open Letter to Junior Doctors from the Royal College of Pediatrics & Child Health in response to the proposed changes to the Junior Doctors’ contract

“Plans to remove the GP trainee supplement, which ensures they have pay parity with hospital trainees, would see a reduction in their pay of around a third.”

 From the BMA Analysis of DDRB recommendations.

3. Changes to pay protection may result in inequalities in pay

Currently, junior doctors who choose to retrain in a different specialty have their pay protected and pay continues to increase annually as per the pay progression described above.  However, under the new contract, retraining in a different specialty will result in a lower salary by default, with only the possibility of some form of pay premium (again the details of this are not clear) for certain trainees to recognise the usefulness of their experience. The value of such premiums will be determined by employers.  In addition, pay may not be protected for junior doctors who take time out of training – for example to undertake aid work. Again, there is only the possibility of a pay premium for reasons deemed to be valuable by employers.  This could result in inequalities in pay for doctors of equal experience across the country.Recruitment and retention problems may also be exacerbated by the removal of pay protection, as it would dis-incentivise any doctor wishing to train in another specialty. 

“The removal of annual increments from those taking time “out of programme”, for example for research training, other additional experience, or parental leave, is damaging to our attempts to promote growth and excellence in paediatric academia, and family-friendly working for mothers and fathers.”

Extract from an Open Letter to Junior Doctors from the Royal College of Paediatrics & Child Health in response to the proposed changes to the Junior Doctors’ contract.

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CONCLUSION

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If a doctor were to intentionally distort the interpretation of clinical risk data and seriously compromise patient safety, there is a very good chance that they would lose their license to practice and could possibly face criminal charges. Many doctors believe that Mr. Hunt should be held to the same standards. A letter, co-signed by thousands of doctors and medical students has been sent to the Cabinet Office requesting that they investigate whether Mr. Hunt has indeed breached the ministerial code of conduct:

 “It appears Mr. Hunt deliberately and knowingly misquoted and misinterpreted the conclusions of a medical research publication in an attempt to mislead the other Members of Parliament and the UK public.”

From a letter to the Cabinet office outlined by Dr Antonio de Marvao and Dr Palak J Trivedi

We want to believe that the government has the best interests of the health service at heart. However, when we consider the situation across the NHS as a whole it is difficult to ignore the pattern that emerges. The system is under severe strain from chronic governmental neglect in terms of a lack of sustained funding increases. The system is becoming increasingly fragmented as a result of major reorganisations (Health and Social Care Act). There have been major cuts in social care provision forcing the NHS to take up the slack. On the back of all this, comes an attempt to destroy the working conditions of one of the major groups of NHS service providers. In light of all this, many of us have been very disturbed to read the quotes from the book that Mr. Hunt co-authored in which he outlines his opinions on the NHS.

“Our ambition should be to break down the barriers between private and public provision, in effect DENATIONALISING the provision of health care in Britain.”

 From ‘Direct Democracy’ by Jeremy Hunt et al

Taking all of this into account, it is hard to imagine that the aim of the current government is anything other than the gradual destabilization and deconstruction of the NHS. Once the system is beyond repair, conditions will be perfect for ushering in a new era of widespread service privatization. The Health and Social Care Act has ensured that there are no solid constitutional safeguards to stop this from happening.

This brings us to the issue of industrial action. The idea of a strike makes many doctors deeply uncomfortable. In light of this, the overwhelming support for strike action demonstrates just how important we consider these issues to be. This is not just a fight for doctors pay and conditions but for the survival of the NHS as a whole. A lot of work is being undertaken by the BMA and doctor’s groups to look at the international evidence surrounding strike action to ensure that any strike is as effective as possible without putting patients at risk.

Doctors will be balloted regarding industrial action from the 5^th November. The BMA wants the following concrete assurances in writing from the Government before it feels able to re-enter negotiations:

• Proper recognition of unsocial hours as premium time
• No disadvantage for those working unsocial hours compared to current system
• No disadvantage for those working less than full time and taking parental leave compared to the current system
• Pay for all work done
• Proper hours safeguards protecting patients and their doctors

This article is taken from the Yorkshire & Humber Junior Doctors’ Protest Group Press Release: @yhdoctors

Junior Doctors – also known as ‘Patient Safety Engineers’

Intuitively, its easy to imagine how the proposed changes to junior doctors’ contracts will affect patient safety. For example, there can be no doubt, that especially in the immediate wake of any imposed changes, there will be significantly elevated levels of occupational stress for many junior doctors, as they carry with them to work their feelings of disenfranchisement heaped upon worries about loss of pay and extended antisocial hours. The myriad ways in which stress erodes the ability of both individuals and teams to deal with complex situations has been very well researched, in multiple settings, including healthcare environments.

 In the context of these proposed contract changes however, the risks to patient safety extend far beyond the consequences of increased stress. Outside the provision of day-to-day work, it is difficult to construct an all-inclusive description that fully depicts the entire spectrum of behaviours that junior doctors undertake to try and keep patients safe. There is, for example, little effort made to try and quantify the enormous amounts of extra time that doctors spend at work out of good will, loyalty and professional interest.* Neither is there any meaningful way to measure the hours that doctors spend outside work keeping up to date with evidence, undertaking research or participating in quality improvement.** Nevertheless, these behaviours are essential contributors to patient safety and by reference to the concept of ‘Health System Resilience’ – an increasingly conspicuous theme within the patient safety literature, it is possible to highlight just how important they are and how they might be affected by the proposed contract changes.

*Of course it’s not just doctors that do this, but almost all NHS staff.

** The #Notfairnotsafe campaign is asking doctors to submit a record of their extra hours for illustrative purposes.

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 Healthcare as a Complex-Adaptive System

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There are certain philosophical assumptions that underlie the way in which policymakers view a Healthcare System. Jeremy Hunt, for example, views healthcare from a very simple, linear perspective. This view imagines healthcare to be comprised of a number of production lines which are the sum of their individual parts. From this narrow perspective, safety breakdowns and adverse incidents are imagined to be the result of the failure of one or more of the constituent parts of a production line. Addressing safety therefore requires no more than identifying replacing / removing / retraining the malfunctioning component whether this be a chief executive, doctor, nurse or any other person / machine / protocol to whom the blame is attributed. This perspective represents a woefully inadequate description of the complex nature of contemporary healthcare. Far from a loose collection of production lines, healthcare is a highly complex system in which large numbers of people, machines and bundles of information are continuously interacting. The NHS is an example of a ‘Complex Adaptive System’ (with multiple smaller CASs within) which is much more like a large, intricate and somewhat unpredictable organism which is constantly adapting to internal fluctuations and external stimuli. Rather than simply spitting out outcomes at the end of production lines, Complex Adaptive Systems ‘evolve’ in certain directions in response to stimuli, producing ‘emergent’ outcomes.

So let’s consider for example a well-functioning High-Risk Maternity Unit as a Complex Adaptive System. One day, significantly more patients come through the unit than usual. The midwifery co-ordinator uses the low-risk birthing unit to provide extra beds for the high-risk patients who still receive appropriate care. Three simultaneous emergencies occur at once – all requiring operative intervention in theatre. Two extra anaesthetists come from other parts of the hospital to help. Two Obstetricians stay well beyond their rotad hours to perform the operations. Midwifery staff, ODPs and HCAs all do the same. All the patients are kept safe and within a few hours, the unit returns to its baseline level of work and the peak in activity has no long-term effects on the functioning of the labour ward. None of the extra hours worked by the doctors will have been logged or paid for. Patient Safety in this situation is an emergent property of a system that has been able to adapt and evolve to unexpected stress. The system is elastic in that it was able to stretch to accommodate the changes and then return to normal quickly with no long term sequelae. Systems that are able to adapt in this way are termed ‘Resilient’. It is easy to see how in this situation, safety is a product of resilience which, in turn, is a complex emergent outcome contingent upon the co-operation, innovation and good-will of the staff.   

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 Doctors as ‘Resilience Engineers’

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Over the past 20 years, there has been a vast proliferation in the number and complexity of interventions available within the NHS. In addition, demographic trends are towards a population that is living longer with increasingly complex medical problems. In spite of these pressures, patient safety has been maintained in a steady state, in a manner which cannot be explained solely through increases in resources and staff numbers. The maintenance of patient safety in the face of rapidly proliferating complexity is a result of the resilience of the NHS as a whole. The evidence suggests that a major contributor to this system-wide resilience is the effort of on-the ground, front-line medical staff who are constantly dedicating extra time to clinical care, developing evidence-based practice, quality improvement, innovation, research etc – all of which allow the system to adapt to ever increasing pressures. Much of this type of activity is unmeasured, unpaid and relatively intangible compared to delivering front line care at the coal-face. Spread junior doctors too thinly and overburden them too much and it is this crucial ‘resilience engineering’ work that may be hit the hardest.

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 A 7-day NHS?

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Most of us will by now, be familiar with Freemantle et al’s 2012 paper about the risks of weekend hospitalization, whose statistics Jeremy Hunt continues to use to justify the plans for a 7-day NHS. In the most recent extension of the work, published in the BMJ in September 2015, Freemantle and his colleagues echo the criticisms of Hunt’s analysis of the data by highlighting the fact that it is still very unclear which aspects of improved weekend service provision might help to reduce deaths (is it more Consultants? access to more comprehensive support services? more staff in general?). Indeed, much of the commentary that accompanies the newest paper questions whether the excess of deaths can be avoided at all through structural or service changes. And so the criticisms of the governments abuse of this very non-instructive data begin to sound much like Antonio’s warning in the Merchant of Venice when he states that “The devil can cite Scripture for his own purpose.”Taking into account Mr Hunt’s comments from 2005 in which he openly admits to wanting to privatise the NHS, a cynic might argue that he is using the mortality figures, overlaid with emotive patient safety rhetoric, to justify major reorganisations that will result in further destabilisation of the system.

The DDRB proposals for extended hours suggest taking the current pool of junior doctors and stretching them out across a 7-day service, without any increase in pay. The proposed way of doing this, is by changing the definition of out of hours’ work. (You can hear the head of the BMA Junior Doctors’ Committee explaining this here). Part of the logic for such changes is drawn from the ‘Lean’ healthcare reform ideology (it is justified to call it an ideology in the absence of good quality evidence). The lean analysis of the current junior doctor working patterns within the NHS favours their redistribution towards this new pattern based on the assumption that there is an excess of doctors working during normal ‘office hours’. In reality, there is no excess of doctors but there is elasticity in the system which is resilient as a result. The evidence suggests that combined with economic pressures, initiatives that seek to simplify and lean down organisations actually whittle down reserves, buffers and other undervalued resources. This makes it very difficult for a system to respond to unexpected changes and stressors – rendering the system brittle. It is the point at which brittle healthcare systems overstretch their elasticity that safety is compromised. Economists call this ‘cost externalisation’ in the sense that it may seem like savings are being made through ‘efficient’ redistribution of staff, but destroying the resilience of the system will cost far more in the long term.  True 7-day working would require a significant increase in staff numbers across the NHS so that resilience engineering behaviour is preserved and the elasticity of the system is maintained across the 24/7 work period.

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 In summary

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So in summary, Junior Doctors preserve patient safety by acting as Resilience Engineers within a Complex Adaptive System. The proposed contract changes risk overstretching and overworking the current pool of junior doctors which will have catastrophic consequences for both the day-to-day elasticity of the system and the evolving resilience of the NHS as a whole. A simpler way to explain this, might be to borrow some metaphors from the Great British Bake Off. Let’s imagine Mary Berry talking about pies. “Pie pastry”, she might say, “has to be rolled just right – too thick and you get a saggy bottom, but roll it too thin and your pie will burst and spill its filling all over the oven.”

 The vociferous, creative and cohesive response that junior doctors have mounted in response to the government’s assault on their pay and conditions, is in itself an act of resilience engineering and it is one that will help to protect the NHS from these repeated attempts at ideologically-motivated political deconstruction.

We’ve found Jeremy Hunt’s book – and yes, he does want to Privatise the NHS.

Note: there is a live link to a pdf of the book at the bottom of this page.

When I try to explain to people that highly controversial NHS reforms, such as the imposition of the new Junior Doctors’ contract, are part of a much wider plan to destabilise and deconstruct the NHS, I am quite often accused of being a conspiracy theorist. Amongst my front-line NHS co-workers, there is a widespread agreement that the government is pushing the health service towards privatisation. But amongst those not directly involved with the NHS, the perceptions are quite different. Many people believe that the NHS is too precious an institution for the Conservatives to destroy without risking political suicide. To justify this position, people will often point to the fact that no-where in any of the Conservative rhetoric or party political literature are there direct references to a desire to privatise the NHS. Well, this is not strictly true. 

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‘DIRECT DEMOCRACY’ by Jeremy Hunt et al.

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Back in 2005 when the Conservative Party was undergoing a prolonged period of navel-gazing after having been out of power for 8 years, a group of ambitious MPs co-authored a book called ‘DIRECT DEMOCRACY – An Agenda for a New Model Party’. Contributors include: Douglass Carswell (of recent UKIP defection fame), Michael Gove and most importantly, Jeremy Hunt. There was some muted reference to the contents of the work in the national media prior to the 2010 election but since then it has fallen off the radar and is in fact notoriously difficult to find. It would appear there is a very good reason for the books’ disappearance – and that is, in part, because it quite explicitly lays outs the desire of the authors, including Jeremy Hunt himself, to privatise the NHS.

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From a  review of ‘Direct Democracy’  in The Spectator –

“One of the founding texts for the new, revitalised Toryism….written by some of the brightest young Conservative thinkers”.

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Here is a summary of some of the key statements.

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Page 74.

The problem with the NHS is not one of resources. Rather, it is that it is a centrally run, state monopoly designed over half a century ago.

This highly pejorative description of the NHS might explain the paltry and grossly insufficient 0.8% increase in funding that constitutes David Cameron’s promised sustained increase. This is a fifth of the average percentage rise that has been seen year on year since 1948 (it has previously been 4% on average).

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Page 75.

A recent independent study of national health care systems placed the UK’s 18th out of 19 countries.

There is no reference to the actual study so no actual analysis of the figures can be made. However, in 2014 The Commonwealth Fund – an Independent US Foundation mandated with analysing Health Policy and Systems from the point of view of providing high quality, efficient care, especially to the most vulnerable in society, assessed 11 Healthcare systems using detailed data from patients and clinicians, supplemented with outcomes data from the WHO. The United Kingdom was ranked first overall, scoring highest on: quality, access, affordability, effectiveness, safety, co-ordinated care and patient-centred care. The US Health Service, upon whose structures many of the surreptitious NHS privatisation reforms are based, scored worst overall in spite of having per-head health expenditure of more than double that of the UK ( £5017 Vs £1876).

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Page 77.

Professor Julian Le Grand, Policy Adviser to the Prime Minister and Professor of Social Policy at the London School of Economics has consistently emphasised the inequalities in the current health system. In an academic lecture in 2004 he said, “Unemployed people and individuals with low income and poor educational qualifications use health services less relative to need than the employed, the rich and the better educated.”

This is a simple re-statement of the Inverse Care Law, proposed by Julian Tudor Hart in 1971.  It is a strange statement to quote as criticism of a nationalised health service because vast bodies of international evidence suggest that health inequality in relation to the healthcare system is most adversely affected in countries where there is poorly regulated private care as the predominant provider. In fact, the full expression of the Inverse Care Law reads:

“The availability of good medical care tends to vary inversely with the needs of the population served. This operates more completely where medical care is exposed to market forces, and less so where such exposure is reduced.”

A centrally funded health service has, in fact, been a major contributor to reducing health inequality by allowing healthcare practitioners and policy makers to design services and deliver care based on need, not profitability. The biggest contributor to health inequality is in fact social inequality, a problem that has deteriorated significantly in the wake of the Conservative agenda of combined economic austerity and welfare reform.

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Page 78.

Our ambition should be to break down the barriers between private and public provision, in effect DENATIONALISING the provision of health care in Britain, so extending to all the choices currently available only to the minority who opt for private provision.

This is the key statement – the open, unambiguous admission that the aim of the Conservative Party’s health policy should be the dismantling of the NHS. The inference from the complete statement is that allowing the private sector to provide services would drive efficiency to such an extent that the government / employers would be able to pay for everyone to have the higher levels of care. Without rehashing the whole public-private debate, one of the main problems with this assertion is that when private providers are introduced, any costs savings generated through efficiency can easily be offset by the need to turn a profit. Regulation of profit margins and service delivery by insurance providers and private healthcare companies is notoriously difficult. For evidence of this you can read about the very recent difficulties that the Democratic administration in the USA have had in trying to regulate insurers and achieve universal access to care with their Patient Protection and Affordable Care Act. A second, huge problem is that many important, complex health interventions are just not profitable. How do you demonstrate profitability in the management of complex, chronic diseases such as Diabetes, Obesity and Heart Disease when they interact with complex social factors that require very long-term involvement from multiple disciplines? When there is difficulty in demonstrating profitability, private enterprises are very unlikely to make investments in developing high quality, innovative services. As a result, there is no equivalent system in countries with predominantly private healthcare that can match the diverse, prolific and highly inclusive primary health system of the UK.

Those of us that oppose the widespread privatisation of NHS services do not do so for ideological reasons. The two-tier system that is proposed in Hunt’s book, where people who can afford high quality care access the private sector and the rest access whatever rudimentary level of care the government decide to provide is exactly the situation that Aneurin Bevan feared would emerge if he chose any system other than a nationalised service. A cynic could argue of course, that using evidence to highlight the benefits of a nationalised system of healthcare is in fact pointless because Conservative opposition to the NHS is ideological,  not pragmatic. That is to stay, that it is a central tenet of the right that health should be treated no differently to chocolate, cars or flat-screen TVs because it is a commodity, that like everything else should only be purchased by those that can afford to pay for it.

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page 80.

Instead of Tinkering with a fundamentally broken machine [the Conservative Party] should offer to update the model, setting out in warm optimistic tones, its vision for a healthier Britain.

All of the recent NHS reforms have been presented in warm optimistic tones – very much in the tradition of a siren-song luring the good ship NHS towards destruction. With regards to the vision for a healthier Britain – see the discussion above.

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page 80.

Our three guiding principles:                                                        

-That decisions should be taken as closely as possible to the people that they effect.

-That policy makers should be directly accountable.                     

-That citizens should be as free as possible from state coercion.

Mr Hunt’s actions with regards to the Junior Doctor Contract reforms do of course violate all of these. This throws into even sharper relief, the degree of disconnect between his political rhetoric and actual behaviour.    

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So there it is, the rumours are true. Jeremy Hunt co-authored a book in which he openly professed a desire to privatise the NHS.

In the next volume Mr Hunt could quite easily outline a Dummie’s guide for Privatising a Public Service……

1. Slowly run the service into the ground.
2. Facilitate a media onslaught so that that public believe that the system and the workers within are failing them.
3. Gradually usher in private enterprise in the name of ‘efficiency and safety’.

Perusing the national press this past week has been like watching such a story unfold in real time. In addition to the government’s farcical behaviour over Junior Doctors’ contracts, the events at Addenbrooke’s Hospital can be seen as a microcosm of the upheavals occurring throughout the NHS. Two hundred of Addenbrooke’s beds are blocked as a result of cuts in council social care and people subsequently being unable to access care at home. The Hospital is spending 1.2million per week above its income to cover the staff shortages arising due to patient overload, a lack of trained nursing staff and an inability to recruit from abroad due to blocks on Visas for non-EU nurses. As a result, citing serious staff shortages as the reason, the Care Quality Commission has downgraded Addenbrooke’s performance assessment to “inadequate” from the “top ranking” assessment that it was given just over a year ago. The decapitated Head of Cambridge University Hospitals Foundation Trust, Keith McNeil, perfectly summarised the impossible position faced by many NHS Chief Executives in the context of this chronic government neglect and under-funding. He observed, that when forced to choose between debt and risking quality, front-line NHS leaders will choose quality every time.

Even from this brief description, it is easy to see how Addenbrooke’s problems stem in large part from the indirect constraints placed upon it by various incrementally damaging government policies. Sadly, their situation is far from unique. Addenbrookes is but one front in a war of attrition being waged against the NHS . It is a war that is 50 years in the making, and it is a war that without our collective resistance, the  Conservative government is going to win.

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A heartfelt thanks to publishers Lulu.com for being the only people to still sell Direct Democracy. If you would like to thank them by buying a copy (it’s only £1) – you can do so here. Otherwise, here’s a link to a pdf copy:

direct_democracy___an_agenda_for_a_new_model_party

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Shareable quotes from Jeremy Hunt’s NHS book….

How doctors can Strike safely and effectively….

At the time of writing, there is widespread anger and dismay amongst Junior Doctors in the United Kingdom at the imposition by the Conservative Government, of new pay contracts due to take effect in August 2016. Broadly speaking, changes in the classification of working patterns, on-call supplementation and pay progression could see many doctors lose up to 30% of their pay. You can read about the details of the proposed changes by clicking the image, or read the BMA summary analysis of the proposed changes here.

Ostensibly, the UK government are suggesting that these changes are essential to drive NHS efficiency, improve patient safety and to bring doctors pay in line with that of other public sector workers. However, the draconian way in which the changes are being enforced and the lack of evidence to support the governments claims have led many to believe that the changes are actually part of a wider ideological deconstruction of the National Health Service, in order to pave the way for a two-tier system with much greater input from the profit-driven private sector. Accordingly, Junior Doctors in the UK are considering widespread industrial action. In this post, we will look at how the Junior Doctor lobby can go about striking in a way that will minimise patient harm, mobilise public good-will and deliver the maximum political impact to bring the government back to the negotiating table.

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THE AIMS OF INDUSTRIAL ACTION MUST BE WELL DEFINED

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Evidence from around the world suggests that contrary to popular belief, doctors can strike effectively and can do so without putting short-term patient safety at risk. However, striking alone will not be enough to effect change. It is crucial that junior doctors undertake their industrial action on the background of very clearly stated aims, which will also have been made very clear to the general public and the government. Two such aims could be:  

1. TO BRING THE GOVERNMENT BACK TO AN OPEN NEGOTIATION    REGARDING THE IMPOSITION OF THE NEW JUNIOR DOCTOR CONTRACT.                                                                                              
2. THE REMOVAL OF JEREMY HUNT AS HEALTH SECRETARY 

Although the Government have given lip-service to contract negotiations, the BMA Junior Doctor’s Committee are of the opinion that the inflexible preconditions that have been presented to them are unacceptable. Hence, one of the stated aims of industrial action could be the instigation of open and flexible negotiations. In the months leading up to these contract changes, Jeremy Hunt has been at the forefront of a media campaign typified my smear and misinformation, the aim of which has been to vilify doctors in the eyes of the general public. The peddling of such misinformation in the pursuit of ideological aims is completely unacceptable. In response, the doctors lobby should accept nothing less than Mr Hunt’s resignation or removal. There is already a petition for this with more than 100,000 signatures. You can add your signature here.

In terms of the practicalities of removing Mr Hunt, doctors can use a model of action based on the series of events back in 2012 that led to the deposition of Mr Hunt’s predecessor, Andrew Lansley. Lansley’s removal came in the wake of multiple votes of no-confidence from professional organisations such as the BMA and NMC. This cemented the widespread perception within the Health Service and amongst MPs that he had mis-sold the Health and Social Care Act in 2012 and that far from delivering much needed reforms to NHS bureaucracy, it led to further fragmentation of the NHS and acted simply as a backdoor to increasing privatisation. We need to frame Mr Hunt’s behaviour in very much the same way – as that of a man completely disconnected from the realities of front line NHS working whose imposition of changes will overall lead to further service fragmentation and  workforce demoralisation – all to the detriment of patient safety.  

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SHIFTING THE NARRATIVE

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Jeremy Hunt claims that the Junior Doctor’s contract will benefit patient safety whilst delivering significant savings to the NHS. Be in no doubt – the public are listening to this story. There is already a widespread belief that doctors are overprivileged and overpaid. In an era of austerity, the emotive pleas from junior doctors about how our lives are going to be ruined by pay cuts fall very much on deaf ears. If you need proof of this, then simply peruse the comments section of any newspaper where the contract changes have been reported.

To get the support of the public and our colleagues, we need to frame this situation in a different way and shift the focus away from the numbers in our pay-packets towards three broader themes:

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1. That this contract imposition will severely effect patient safety.

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2. That the decimation of junior doctor conditions and morale is part of a bigger program of NHS deconstruction.

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3. That after Junior Doctors, the government will remove unsociable hours pay for Nurses, Midwives, ODPs, Physiotherapists and Healthcare Assistants – that is to say, all of our colleagues and friends will be next.

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One emerging theme from the Patient Safety literature relates to the role of front-line doctors in maintaining the resilience of the NHS. Resilience in this sense denotes the ability of the system to adapt quickly and continue delivering safe care in spite of rapidly increasing complexity related to patient needs, healthcare technology, financial constraints etc. The evidence suggests that in spite of the increasing pressures on the system over the past 20 years, patient safety has remained stable. One of the most crucial contributing factors to the resilience of the system is the leadership role played by frontline Junior Doctors. In this complex environment, doctors’ leadership and efforts based on goodwill (i.e. not financial remuneration) facilitate adaptive outcomes such as system learning, innovation and adaptability.  The changes to the contract will undoubtably result in an acceleration of the exodus of Junior Doctors from frontline services. Those left will be under significantly more pressure from both the increased workload and the psychological effects of being severely undervalued and disenchanted. The resilience of the system will suffer. Many frontline services may have to close. Services will have to be centralised. This is the story that we need to tell the public and our colleagues. Do they want to lose their GP surgery or local hospital? Do they want to be seen / treated / operated on / counselled by an unhappy and undervalued Doctor? How do they think this will affect the doctor – patient dynamic? 

If we allow the government to pull this thread, the whole system may begin to unravel. This is the story we need to tell. Our industrial action needs to be framed in defence of the whole NHS so we don’t come across as a group of over-privileged public sector workers, complaining and marching whilst people’s operations and outpatient appointments are delayed.

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THE PRACTICALITIES OF A JUNIOR DOCTOR’S STRIKE 

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There are two ways that doctors can strike – partially or completely. The complete strike is a rarity and is almost invariably restricted to low-income countries with poor health infrastructure. A complete doctor’s strike does of course result in deaths, often many hundreds of deaths, but in countries where doctors are revered and relatively few in number, public opinion usually remains firmly in their favour. So in the UK, the maximum intensity of strike action that would be morally and ethically acceptable to both doctors and the public would be a partial strike. In practical terms, this would most likely take the form of Junior Doctors declining to participate in elective clinical work such as outpatient clinics and planned, non-emergency operations.

Even this level of strike action however will make many junior doctors deeply uncomfortable. Although the most comprehensive review of mortality in relation to doctor’s strike action has shown that there is often actually a decrease in short-term mortality during partial strike action (most likely due to the lowering of complications seen during elective operations) many doctors will still feel that any form of industrial action is a violation of their duty of care. There are also the issues surrounding treatment delays which may affect long-term mortality, not to mention the fact that it is the striking doctors ourselves that will have to redouble our efforts to help clear the backlog of work upon our return to practice. Finally, there is also the chance that a strike may actually backfire and further strengthen the government’s position. During the 2006 Junior Doctor’s strike in New Zealand for example, many of the duties of Junior Doctors were taken over by Consultants. What happened was that A&E waiting times actually improved and patient flow through Acute Medicine departments improved. If a similar pattern were to emerge during a UK strike, it would provide ample opportunity for spin and for Mr Hunt and others to further undermine the value of Junior Doctors in the eyes of the public.

The government is undoubtably aware of all this. They know that because doctors are unable to stage a complete strike, we have relatively limited power when it comes to contract negotiations. This is why they were able to present completely unreasonable negotiation preconditions to the BMA’s Junior Doctor’s committee.

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A COMPREHENSIVE RESPONSE

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So a partial strike alone is unlikely to bring the government back to the negotiating table in a meaningful way. This is an important point, because in social media circles and the press, a Junior Doctor’s strike is being mooted almost as an extreme last resort to force the government’s hand. What is required instead is a much more comprehensive and nuanced response in which we frame the systematic destruction of our working conditions and morale in the context of the wider dismantling of the NHS.

Ironically it is one of the most frequently employed tactics of neo-conservative governments to use external threats (perceived or real) as a way of both increasing societal cohesion and government control over society. As a group of highly motivated  professionals who spend their lives working in teams to keep patients safe,  Junior Doctors should use this threat to our working conditions as a stimulus for cohesive and co-ordinated action directed towards protecting the NHS. 

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SOME SUGGESTIONS AS TO WHAT TO ACTUALLY DO….

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· TALK – talk to everyone, friends, family, colleagues, your bosses, and strangers. Talk about the NHS. Talk about the importance of resilience in the healthcare system. Talk about how you think stress and demoralisation will affect care in your particular niche. Comment on websites and social media – but don’t rise with anger to the doctor bashers. Presenting them with figures about our pay is often unhelpful and may even help fortify their position.

· LOBBY – write to your Royal College, your MP, tweet the Shadow Health Secretary, the Leader of the Opposition. Go the meetings being organised by the BMA and NHS employers. Lobby the BMA to pass a no confidence vote in Jeremy Hunt. Write to the GMC. Sign the petitions. Speak to your local representatives from the NMC and UNISON – highlight your concerns that the next pay cuts will be to our NHS colleagues.

· STRIKE – Join the strike – it is safe to do so. It is highly unlikely that the strike will involve acute services. But when the time comes and the public see doctors marching, they need to see a group marching to protect them and the NHS. And if you do strike make sure that you are protected. If you are not a member of the BMA, your employer may be able to take action against you for violation of your contract. You can join the BMA here. It is free until 30th September.