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.
Healthcare as a Complex-Adaptive System
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.
Doctors as ‘Resilience Engineers’
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.
A 7-day NHS?
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.
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.