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.
Patient Safety : The Narrow View
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.
The Trojan Horse
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.