Junior Doctors – also known as ‘Patient Safety Engineers’

Intuitively, its easy to imagine how the proposeEnginBandaidButd 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.

 In summary

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. 

‘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.

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”.

Here is a summary of some of the key statements.

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).

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).

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.

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.

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.

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.    

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.

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: