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.