All in this together….or not?

I have been asked to write something about ‘why I became a doctor’. The best answer I can give to that question is simple and it reminds me of a line from Animal Farm; “it was not for this that she and all the other animals had hoped and toiled…such were her thoughts, though she lacked the words to express them”.

It was not for this.

Should I expand? I think I am expected to give you a heartfelt story about who I am and why I am here. I’m not sure I can be that person. The idea of course is not far fetched. Perhaps a window into my background could strike a chord with one, or many. Perhaps that would bols
ter support.

The thing is though; this isn’t the X Factor.

Don’t get me wrong; I have a story, but I think in reality everybody does. My patients have stories. Every single one of them has come down a path that’s a little bit different from the patient that left the bed before them. I’ve looked after British men who fought in World War II, I’ve looked after a man who had been forced to flee nazi invasion in Poland and I’ve looked after a man from Germany’s Luftwaffe who made a new life for himself here after his aircraft fell out of the sky in Scotland. I’ve looked after a lady who was a scullery maid when children were not given the chance to be children. I’ve looked after top class athletes who found their entire world destroyed suddenly by accidents. I’ve looked after people with money and status, people whose names might be on the pages of a magazine and I’ve looked after people who came with no known name and no next of kin.

We all have our own stories. When I stand beside my patients and ask them to trust the care I will give them however, it is what we have in common that matters. A consultant once told me that the beauty of a nationalised health service was not just that it is a healthcare system that is free at the point of use for everyone, the beauty of the NHS is that we were all in it together. It does’t matter if you are a doctor, a nurse, a porter, a chief executive officer, a policy advisor in the department of health or a volunteer for the league of friends cafe; you are also a patient. We are all in this together and if that truth fails, things will fall apart.

Junior doctors have been lied to and lied about. The proposed contract will not help the NHS and it will not improve services. There is no evidence linking the new contract to safety, improved mortality or improved staff performance. Government leadership has consistently pitted itself against junior doctors and my worst fear is not that I will get a pay cut, but that they are already no longer ‘in’ this with us, that they are no longer ‘in’ this with you.

Junior doctors cannot bow down to the threat of imposition for one reason and one reason only; we are all in this together and honestly, we need all the help we can get…because if we fail, things will fall apart.

vaetchanan-we-are-all-in-this-together

Junior Contract & The Generation Gap

It wasn’t my initial intention to write this. In January, ITV news asked me to write something with a view to explaining my rational for participating in the first emergency cover model strike by junior doctors. The next day they published an article by retired Dr Henry Goodall: entitled “Current generation of doctors work less hard for more money and fewer hours”.

In his article Dr Goodall opened by referring to me by name, lamenting that my writing had made him ‘sad’.  Reading through his article, Dr Goodall goes on to explain his experience as a newly qualified doctor in the 1970s. My thoughts on the usefulness of this sort of argument is not something I will really get in to here. It is enough to say that I am a big enough person to know that both generations of doctors experienced a different life. Each came with different pressures and different problems. Dr Goodall does not need my validation to know that the truth he is speaking was real for him. I do not need Dr Goodall’s validation to know that truth I speak is also very real for me. George Orwell said “every gemusic-gen-gapneration imagines itself to be more intelligent than the one that went before it, and wiser than the one that comes after it”. For my part, I aim to have respect for the generation of doctors that came before me and it is my experience that the majority of senior consultants and GPs reciprocate.

Since Dr Goodall’s article I have heard his opinion quoted by several other news outlets. More recently, he has made a national broadcasting appearance and so, while it was my intention to let sleeping dogs lie, so to speak, it is clear that as a generation of doctors we are not to be given the same courtesy.

Shortly after Dr Goodall’s ITV news piece, I became aware of an article also by a Dr Henry N Goodall “Why I became an Occupational Physician”. The passages below have been taken from it.

“…I began to realise that…I could not longer practice medicine to the standard to which I had been trained in the National Health Service general practice, which was then being suffocated by stagnant bureaucracy and poor morale”

“I could see the future of the NHS and knew that it would take 10-15 years to happen. Several GP colleagues had fallen victim to illness, due to overwork. I decide that I wanted to live beyond the age of 50 years”

The article continues to chart Dr Goodall’s journey to full time occupational medicine , starting with his post at The Ford Motor Company.

I do not think it is necessary for me to say much more. Those are apparently Dr Goodall’s own words. It may however be interesting for him to know that I also feel ‘suffocated by stagnant bureaucracy and poor morale’ and I too know the pain of having to see colleagues physical and mental health suffer.

So in the end, it would seem we are not so different after all.

Why Jnr Drs will never be led by Jeremy Hunt

2015-11-18-1447858531-9338860-FullSizeRender-thumbOn Sunday 7th February, Jeremy Hunt was interviewed on the Andrew Marr Show. This could have been an opportunity to appeal directly to those who have lost so much faith in his leadership. Unfortunately the reality was anything but.

The interview opens with a small conversation about Jamie Oliver’s proposed ‘sugar tax’.

J Hunt (JH): As he said, and I mean obviously it’s Sunday morning and people are tucking into their bacon and eggs and chocolate croissant and whatever and I don’t want to be too much of a kill joy, but he is right….

Yes, it is indeed ‘obviously’ Sunday morning. I am in work though. If you’re interested I actually worked last weekend too; so no “bacon and eggs and chocolate croissant” for me then either

Andrew Marr (AM): All right. Let’s move to the junior doctor’s strike. There is a central sort of poisonous misrepresentation which I think has made this a particularly bitter dispute, which is your assertion that the 11 thousand extra deaths at the weekend are connected with poor staffing by junior doctors in hospitals. That drives them absolutely insensate with anger and it’s not true.

JH: Well the truth is that junior doctors are right to say that as we deal with the higher mortality rates at weekends it isn’t just about junior doctors. It’s about being able to get diagnostic tests back at weekends, it’s about consultant cover.

AM: Absolutely yeah.

Well isn’t that nice? It isn’t just about junior doctors. Strange though, I think any member of the public would be forgiven for thinking that it was all about junior doctors.

Perhaps if we all felt there was actually a  ‘7 day plan’, we’d feel differently. It was not so long ago when, following a speech where Mr Hunt famously referred to his ‘plans’ a many as eighteen times in one speech, that Dr Mark Porter, Chair of the BMA, took out an entire page newspaper advert simply to ask ‘when will the Prime Minister define what he means by a ‘truly seven days NHS’?

JH: But, if you look at – we’ve had I think now 8 studies in the last five years and they are – they all say that staffing levels at weekends are one of the issues that needs to be serious –

AM: One of the issues, but not – and Sir Bruce Keogh, who did the report, has said that it would be rash and misleading to suggest that these deaths are avoidable by changing staffing.

JH: He actually said that it would be rash and misleading to say that you could avoid every single one of those deaths, but he also very clear that staffing levels matter. And I think one of the unfortunate misunderstandings – junior doctors work incredibly hard; they are some of the hardest working people who do some of the most weekends and nights and we need to support them to do their job better. I think when we deliver a seven day NHS, and this is the end is about making the NHS the safest, the most high quality system in the world. The first thing I had to deal with as Health Secretary was the tragedy of Mid Staffs, and I’ve learnt from that that when you have these studies that say you’ve got these problems you can’t duck them.

So Mr Hunt has said that junior doctors work very hard. This is true, the entire NHS workforce are coping with enormous strain. We work hard.

But he has also suggested that we need to ‘do our job better’. I wonder what part of my job I need to ‘do better’? Am I not trying hard enough to make up for the gaps in rotas already putting a strain on services as they stand? Do I not already give every part of my that I reasonably can to the patient in front of me. Do I not already devote vast amounts of my personal time to professional development?
It seems to me that if Mr Hunt actually wanted to ‘support (junior doctors) to do their job better’ he would be focusing a bit more on the support and less on the junior doctors. If Mr Hunt really did in fact intend to make me feel ‘supported’ to do my job ‘better’…my hasn’t he failed?

I’ve never felt lower and less supported. I’ve never felt more serious that perhaps staying in the NHS in England isn’t for me.

AM: But you have connected those excessive deaths to the whole question of rostering and junior doctors and that is what people think is misleading, because it’s a much more complicated situation than that. Many of those deaths are caused by the fact that people who go into hospital at the weekends are already iller and therefore much more likely to die. And Sir Bruce Keogh and many others have said you can’t connect the number of deaths to rostering questions and yet you have.

JH: Well that’s not true. If you look at those studies ……. they all say, the Royal Colleges say that you have got to look at staffing levels. We have three times less medical cover at weekends. Now we’re never going to have the same levels because there are going to be lots of things – and I think this is another misunderstanding – there are going to be lots of things that we don’t do at weekends, hip operations, knee operations and so on…..

Sorry to interrupt here Mr Hunt, but it’s Sunday, i’m in work and there is actually a ‘hip operation’ going on down the corridor.

(JH)…but for urgent and emergency care – If I give you one example which actually relates to senior doctor presence, the clinical standards – and this is all about making sure we meet the clinical standards, they say that if you’re admitted to hospital you should be seen by a senior doctor within 14 hours. That currently only happens in one in eight of our hospitals.

Again, I’m interrupting you before you’ve finished. I’ve worked as a medical registrar…all my new admissions were seen by consultant within 12 hours. All of them. If however this is a problem in other hospitals, this junior doctor contract won’t make a blind bit of difference and I’m really not sure why you’ve mentioned it.

(JH)…Now if we want to promise – if we want that to happen across seven days to week, if we want to promise every NHS patient, as I do, that they’re going to get the same high quality care every day of the week, then we have to look at these issues.

It remains incredible to me that Mr Hunt continues to back up his arguments with examples that are not relevant to the doctors he is actually imposing a contract on. I don’t mean incredible in a positive way. I mean that I literally cannot wrap my head around the fact that we have reached such a serious point in this dispute and this is still happening.

Even if we pretend he had given a relevant example….what have we actually learned so far?

Mr Hunt thinks that i would be better to have more staff on the ground at weekends. Great. This seems sensible; lets get MORE staff!

How you will do this in the wake of a row that has now completely destroyed the relationship between junior doctors and the department of health I don’t know. How you will do this when it appears there are no substantial plans to actually get more staff I don’t know.

GP training applications from FY2 doctors are already down 25% since 2013. I think it’s safe to say that the legacy of this dispute has already cast a shadow over medical training in the NHS in England.

AM: I definitely want to return to that, but just to stay on this central question of misrepresenting the position of junior doctors, I can quote to you two things you’ve said. ‘There are 11,000 excess deaths because we do not staff our hospitals properly at weekends.’ And you’ve said that ‘excessive overtime rates give hospitals a disincentive to roster as many doctors as they need at weekends and that leads to 11,000 excessive deaths.’ Against Sir Bruce Keogh who did the research who says, ‘It is not possible to ascertain the extent to which of these 11,000 deaths may be preventable. To assume they are avoidable would be rash and misleading.’ So when the Editor of the BMJ accuses you of misrepresenting that report she was right.

JH: She was wrong…..

Dr Fiona Godlee, Editor in chief of the BMA is wrong; just simply wrong?

Dr Godlee was educated in medicine at Cambridge University, she is a fellow of the Royal College of Physicians, former Harkness Fellow at Harvard University, has served as president of the World Association of Medical Editors and is currently chair of the committee of publication ethics. Mr Hunt’s crude dismissal of expert opinion here is in fact one of the most frightening things I have seen him do.

‘She was wrong’

(JH)…….. And if you look at Bruce Keogh said there he didn’t say that what I said was wrong; he said it’s wrong to say that you could avoid every single one of those deaths, but he also confirms that staffing levels are one of the issues that need to be investigated amongst many other issues.

Here we are back to staffing levels again. Not the only issue, but apparently the one at the top of your agenda….and yet there are actually no feasible plans to have more staff.

Spread the jam thinner if you will: I can promise you it won’t taste the same.

(JH)…….And look, in the end, it’s intuitively a very sensible thing to observe that if you don’t have enough senior doctors when people are admitted to hospital at weekends, if you’re not able to check for example the most vulnerable patients twice a day, which is what the clinical standards say, then your risk of a death that could be avoided is higher. And I came into this job wanting to make sure that we offer the highest standards of care for every single patient. And I think the sad thing about this is that you know we’re going to have a strike on Wednesday and actually what I want to do is what every single doctor wants to do. They want to give the highest standard of care to their patients. And what we should be doing is sitting around the table discussing how to do this rather than withdrawing care from patients which can only harm them.

Again ‘senior doctor cover’! If you are going to impose a contract on thousands of junior doctors, the least you can do is back up your decision with references that relate to junior doctors.

If this wasn’t so serious, it would be funny.

AM: You have said again and again the phrase, ‘senior doctors.’ Why go into head to head confrontation with the junior doctors who are the very people who are actually staffing hospitals at the weekends and who are not responsible for 11,000 – can we agree that they are not responsible for 11,000 deaths in hospitals over the weekends?

JH: I think there are a number of things that are leading to these –

AM: Can we agree with that to start with at least?

JH: Well there are a number of things. If you look at the study – I think, you know, you’re saying to me that we need to be very careful with our words and if you look at the studies they all say there are a number of factors that need to be investigated, including staffing. But if you just look at this contract, and I think there have been a lot of misunderstandings, but look at the crucial issue of pay, because I think this something that worries people. We are absolutely clear that we don’t want to cut junior doctors’ pay, in fact for the majority of them it will go up. If you look at the

Mr Hunt you didn’t actually answer the question. Why do you keep referring to ‘senior doctors’ when we’re talking about a junior doctor contract? Are you aware that you are not answering the question?

AM: Sorry, just on pay, you said something that I don’t understand at all, you have said that this is revenue neutral, you’ve used that phrase, it’s not going to cost any money at all, and you’ve said that 75% of junior doctors are going to be paid better – have more money coming in – and the rest won’t be worse off. That is mathematically impossible.

JH: Well, in the short term, as we transition to the new contract it will be actually cost us more.

AM: It will be more in the short term.

JH: As we protect the pay of people as we move to the new contract, but when we move through to the new contract in four years time the total amount going into the jnr doctors pay packet will be higher, not lower and so –

AM: So it’s not revenue neutral?

JH: Well it will actually – you know in the end if you’re going to ask more doctors to work at weekends…

AM: You’re going to have to pay more money?

JH: You’re going to pay more, but in order to be able to afford that, to do that in a way that’s affordable for the NHS we do need to reduce – this is a very important point – we need to reduce the premiums that we pay at weekends, make up for it with an increase in base pay, but even after these changes that we’re making jnr doctors will get a higher premium for working at weekends than the nurses working in the same hospital, than the ambulance drivers who take people to hospital, than the porters, than the cleaners. It’s a good deal for junior doctors. But most importantly it will make care safer for patients, because what we need to do is to make sure that our hospitals are properly staffed at weekends.

Firstly, I would like to see the actual evidence that actually links this new contract for junior doctors to ‘safer care at the weekends’.

Secondly, you say doctors will get a higher premium for working weekends than the nurses working in the same hospital. I would therefore like to draw attention to the Agenda for Change unsocial hour payments. Now don’t get me wrong, my colleagues work hard and deserve every single penny they earn. The majority deserve more. Not only do band 1 – 9 health care workers get extra payment for working anytime on Saturday, these extra payments range from time plus 30% to time plus 50%. Sunday payments range between time plus 60% and time plus 100%.

unsocail hours

I could be wrong here, but isn’t what you have said therefore grossly miselading?

If you meant that doctors get paid more money than nurses and porters and cleaners generally; I don’t think this is news is it? I really doubt that can be your point.

AM: If it’s such a good deal why do you have to protect their pay for three years?

JH: Well because what we’re actually doing in this change is we’re giving more rewards to people who work the nights and the more frequent weekends and I want to make sure in the transition – it’s a very complex business – that there are absolutely no losers.

‘A very complex business’ – A teacher once told me that if you don’t know something well enough to explain in clearly to somebody else: you don’t know it.

(JH)…What we’ll end up with is a contract that is better for patients, but also better for doctors. Now if you’re a jnr doctor at the moment and you go to work at the weekend, you will find in an A&E department we have half as many consultants on a Sunday as we do in the week –

AM: I’ll come back to –

JH: No, let me just finish this is very important. So it’s a very stressful experience. Now what I want to do if for jnr doctors to know when they go to work, whichever day of the week, they’re going to get the support that they need to be able to give the best care to patients. And you know, this is obviously very challenging. The BMA is a very formidable union, I mean health secretaries, you look at the battles that Ken Clarke had, that Nye Bevan had, you know, health secretaries have these battles but what history judges if in the end have you done the right thing for patients?

Mr Hunt, this was beyond a joke before Christmas and it is beyond the scale of ridiculous now; the junior contract does affect senior doctors and imposing it will make not an iota of difference to consultant presence in A&E at the weekend. I feel like I’m repeating myself a lot here.

You still haven’t answered that question though; Why do you have to protect pay for three years?

You have said that you want to make sure there are no losers ‘in the transition’: I will be honest here and tell you that to me, that sounds like you want to be sure that those who will know what they are missing, because they are already on the old contract will have a reason to keep quiet. It feels like I am being asked to sell out those yet to come up through the ranks.

Maybe if questions in interviews like this were actually answered appropriately I would feel different.

Do you have any appropriate answer? If you do, I cannot stress enough that now would be the time to give it.

It is not in my nature to be wilfully disrespectful or rude to another person. I do not go in for overly sarcastic jokes or comparisons when I write because to be honest, it strikes me that sort of talk will only ever appeal to people that already support you. Following the announcement of yesterday’s imposition, it is infinitely clear to me that the future of the NHS will never be secured by the current relationship between junior doctors and the secretary of state for health. This has been proved by each interview he has given on the topic. They are his words.

I will be a junior doctor for ten years. I will be a consultant for thirty or more. I have at least 35 more years to give the NHS, I am the future of the NHS; but I will not be lead by Jeremy Hunt.

PS – if you’re interested in another interview in which Mr Hunt gave on the junior contract row…while saying very little about the actual junior doctor contract you might be interested in this.