We will not move backwards

strong-woman.jpgMy maternal grandmother was born in 1923. In 1945 she worked as a laundress in Dublin. This was back breaking work, the sort of toil that makes Friday night on the floor in A&E look like an easy ride. In the Summer of that year she stood with 1,500 laundry workers on a picket line with the Irish Women’s Worker’s Union to demand not one, but two weeks paid holiday from her employer as a basic entitlement. The strike was monumental for more than one reason. Other working class unions identified with the laundry women’s struggle and offered support where they could, the power of the ruling classes, government and even the church hierarchy however rallied around the wealthy business owners and as a result the strike was dragged out over some fourteen weeks. For working class women in the climate of post war Europe, this hardship was not to be sniffed at; but they persevered.

Secondly it was a strike by women, who stood firm in their worth at a time when they did not have the luxury of being able to expect equality and when they won, they won a right which was extended to all Industry workers in Ireland.

In 1948, my grandparents married and over the next 15 years between 1949 and 1964, my grandmother had twelve children. When the youngest of her children was about 9 years old she returned to work as a cleaner in a hospital and continued this work until she was seventy years old.

In 2012, the British Medical Journal (BMJ) quoted Professor Jane Dacre, then medical school director of University College London as saying

“when the 2007 female cohort [of specialty trainees] become consultants, female consultants will be 55% [of the workforce]. So feminisation is a fact. There is a tsunami of women coming through” .

women docsPersonally, I take a little issue with an increase in female consultants being compared to a natural disaster (!) but 9 years later it is interesting to note that according to NHS employers current data, the proportion of female doctors employed as consultants is actually still just 32%. The interest in a growing cohort of female doctors at this time sparked the BBC headline ‘women docs weakening medicine’….a headline which has been be periodically dragged out since, perhaps most notoriously in recent times by Dominic Lawson in The Times.

My grandmother was a tower of strength. She was a giant and I have told you her story because it is one of the reasons I am lucky enough to have grown up knowing the truth; that feminine is anything but weak. To me, the idea that the association of female workers with weakness has continued to drag at the heals of female doctors, even in the twenty first century, is unbelievable. More than unbelievable though, it is just wrong.

You will understand now why, when I tell you that the idea that being female would ever be seen as a negative attribute when I became a doctor was not what I expected at all. Thoughts like that were just not part of my world. When I was half way through my medical degree however I was assigned a placement in intensive care at a district general hospital. As is the norm, I very much looked up to the male consultant we were attached to, but when I told him it was my dream even back then to do intensive care medicine as a career, he told me it was not a career for females. When I left the hospital that evening, my world fell apart. Dramatic as it sounds, I was honestly devastated. It was like I had been hit with a wrecking ball; all this time I had no idea I was inherently inadequate and what was I supposed to do with my dreams now?

Thankfully this was just a temporary break in my self esteem. I soon remembered who I was and where I came from and I have never encountered a similar attitude from any of my intensive care mentors since. In fact my experience since has been very much the opposite and I have some consultants at University Hospital Coventry and Warwickshire to thank for that.

Yesterday The Department of Health Published it’s own equality impact assessment (EIA) on the junior doctor contract they have lined up for imposition and we were reminded that the facade of support for gender equality in the workplace is depressingly fragile. As a female I read the words with absolute disbelief and perhaps simultaneously the most comforting and frustrating thing is that every single male doctor I have spoken to has shared the same reaction.

“We consider that any indirect adverse effect on women is a proportionate means of achieving a legitimate aim”

“…could give rise to inequalities implications…..but if this were the case we consider that any impact would be justifiably legally as indirect impact resulting from a legitimate aim”

“…while this may disadvantage lone parents (who are disproportionally female)….in some cases this may actually benefit other women, for example where women have partners…”

I will not linger on the point that the ‘legitimacy’ of aims are only as trustworthy as those in charge and that so far, The Department of Health have not at any stage proved that their association of the new junior doctor contract with a so called ‘seven day NHS plan’ is remotely justified. Their aims are far from legitimate and if you take one piece of truth from this writing I would like it to be this, that junior doctors have never been a barrier to improvements in NHS services.

The language used by the department of health in their EIA is both frightening and deeply concerning. But this time, I have absolutely no intention of letting my world fall apart, temporarily or otherwise.

The question of course is where do we go now? This is not something I know the answer to, but I know this much; we will not go backwards. We will not accept a contract that attempts to once again kindle the discrimination of female doctors in the medical workforce.

So let me be clear Mr Hunt, I am a female doctor, I am an asset to our NHS and I will not be collateral damage in your plans.

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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.

Am I part of your problem?

 

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I have been thinking a bit about doing things I don’t want to do. About what makes people oblige when they wouldn’t obviously be inclined to, specifically when the rewards of doing so don’t seem to be particularly tangible. This train of thought took me back to a length of time I spent working as a medical SHO for a trust in special measures. Coming out of that time on top was a credit to the trust, to the staff that work there and the community that fought for their district general hospital to stay. My part was entirely insignificant, but I had a part and as I’ve come to realise the NHS is a shining example of emergence; the result is greater than the sum of its parts.

Recalling my time at that trust, it is entirely clear to me why I worked so hard, in my own small way, to help that trust achieve their goals: every single step of the way, I felt like part of the solution.

Is there vanity in that need? Perhaps, but we are all human. I am not ashamed to say that feeling like a part of the solution to something probably makes me more likely to achieve a goal, even when I know it will be difficult. In the case of my time at that hospital, it didn’t just mean that I was more inclined to fill in reams of paperwork and care bundles for which I didn’t always see the point, it meant that I felt secure enough to take responsibility for the things that needed to change. I felt safe enough to recognise that yes there were things I could do personally to help with patient flow. I felt secure enough to accept that my ward could communicate better with patents and their relatives. I was able to recognise there were problems because I knew that I was part of the solution.

Lets compare that situation to the employee relations disaster that has become of The Department of Health’s plans for a new junior contract. The difference, once you look for it is standing in the room like a great pink elephant; they told us we were part of the problem.

In July 2015, Mr Hunt told us that we had a ‘Monday to Friday culture’. We were part of the problem. He told us that we needed to bring back a ‘sense of vocation and professionalism’; we were part of the problem.

In the DDRB report NHS employers told us that they needed to create a contract which didn’t give us ‘incentive to work slower’; we were part of the problem. They told us that they didn’t want to create a contract where we could claim money for ‘every extra minute spent carrying out duties’. We require to be paid for the work we do; we were part of the problem. They told us that our incentives to stay and help patients who required it outside of our rostered hours were ‘perverse’ – we were part of the problem.

In October 2015, Mr Hunt told the us that our request for appropriate recompense for working unsocial hours is ‘punitive’ to hospitals; we were part of the problem.

Is it any wonder that junior doctors find themselves obliged to be at arms?

But the car crash in employee relations continued because when tens of thousands of junior doctors, like me, became unsurprisingly impassioned and enraged by this treatment, we were accused of ‘militancy’. Mr Hunt was quoted by The Mail on Sunday drawing on language synonymous with battle, that can only be viewed as harbouring a sense of aggression:

‘I have never crumbled in any of the challenges I have faced as Health Secretary….there’s no point doing this job if you aren’t up for the fight.’

His comments of course appeared the same month as this tweet where he apparently endorsed the alignment of part of the junior doctor campaign for a fair and safe contract as ‘militancy’.

JH tweet

NHS employers and The Department of Health had the opportunity to make 50,000 junior doctors part of their solution for a ‘better NHS’. Instead they told us we were part of the problem, and where do we go from there?

Between a Rock and a Hard Place

The news came yesterday that junior doctors are once again on the brink of a season of industrial action. Disappointing as the news was, it was not unexpected. For many of us there is a persistent feeling that our real concerns are not actually being entertained by the Department of Health. There is a underlying current of worry that the ill advised contract reforms presented during the Summer of 2015 are part of a bigger and much more worrying plan for the NHS. It is undeniable at this stage that there really is scant bedrock of trust left to build a relationship on. Indeed yesterday the Department of Health accused Dr Mark Porter, chairman of the BMA, of refusing to discuss a revised offer which had been provided to him over the course of the weekend. The BMA claim they did not in fact receive this offer until 11am yesterday….small things, seemingly chipping away at the hope of rebuilding a relationship between junior doctors and the Department of Health. I have quoted before Einstein who told us that “whoever is careless in the truth with small matters cannot be trusted with the important matters”. Did he have a point? At times like this, it certainly feels that way.

Mr Hunt’s most recent correspondence heralded a new player into negotiations; Sir David Dalton. Sir David is a long-serving NHS chief-executive officer (CEO) once named as being in the top ten most highly paid employees in the English NHS. The trust he is responsible for has I am told has gone from strength to strength under his leadership. Salford NHS trust has indeed received an ‘outstanding’ CQC rating on multiple elements of their care. I am not for a minute doubting that Sir David is good at his job, nor would I claim to be able to refute that he is anything but a dedicated hardworking and valuable member of the NHS team. The climate of change in the NHS however has unfortunately left those at the coal face with the skills to actually deliver care, in real time, short changed by the focus on corporate solutions to leadership and change. Earlier this week the Telegraph told us that five CEOs earned an average of £238,000 last year. To put that in context, it is ten times the average nursing annual salary. There were in fact incidences apparently where bonus payments alone constituted more than a nurse’s yearly salary. The national health service is a institute which requires many of its workforce to accept lower pay than they would otherwise earn privately. The idea of ‘value of money’ when it comes to corporate leadership is too ambitious an issue to unpick here but safe to say that in the context of NHS austerity measures it is obvious that health care staff will wonder why management continue to be treated so differently. These stories represent a difficult pill to swallow. When it comes to interacting with top down leadership in the NHS, the junior contract row is if anything drumming up large pockets of mistrust and skepticism among junior doctors. The interface between corporate and coal face is crumbling; if the way becomes blocked, I very much worry for the future of leadership within the NHS.

Salford’s most recent annual report reads very well. It talks positively about respecting safe staffing targets and creating opportunities for junior doctors to become engaged in education and leadership opportunities. The CQC specifically commended the trust on their success in dealing with increased demand for Accident and Emergency (A&E) services. This achievement is of course sure to be on the wish list of doctors and the Department of Health alike. Their successful strategy, we are told, included increased investment, redesigning supportive infrastructure for patient flow, developing new models of care outside of hospital, re-designing the estate to separate minor injuries and re-aligning staff to this. It did not necessitate any contract reform for junior doctors. Indeed they have apparently become one of the most exemplary trusts in the country using the current contract.

The report does however go on to lament that investing in capacity to increase activity levels appropriately left them dependent on a temporary workforce paid at increased rates. The suggestion that temporary staffing are draining the finances of the NHS will not come as a surprise to junior doctors; we routinely work along side those getting paid twice, three times or more our equivalent hourly rate to do the same job we do on a training contract. It is also worth remembering that planned contract changes will not only be irrelevant to locum staff, but are also exceedingly unlikely to tempt any out of locum work and into vacant training posts. Salford’s productivity improvement project ‘Better care for lower cost’ has resulted. At least we can say this plan is what it says on the tin. Better care for lower cost; a cost saving exercise with the idea of improving care. This plan too has presumably been created without changes to junior doctor contract. Salford recognised that supporting increased activity required more money and now going forward, they need to save money. The Department of Health continue to tell us that junior contract reforms are not a cost saving exercise at all. Is it a wonder we don’t believe them?

In an interview on BBC radio 4 today, Mr Hunt again extolled the Department of Health’s promise of pay protection for 99% of junior doctors.  With respect to this however there are some obvious questions which unfortunately media outlets seem unwilling to ask:

1. If this is not a cost saving exercise, why do large swathes of junior doctors require pay protection in the first place?

2. When the pay protection time frame runs out, won’t we in essence just have sold out thousands of our colleagues who remain in training or are yet to graduate?

As a junior doctor, I continue to rely on the effectiveness of the BMA to negotiate on my behalf. As the row continues I remain firmly stuck, between a trade union I have come to trust and a government I am struggling to maintain any faith in. I stand between the two with my hopes, my dreams and most importantly I stand there with my patients.

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‘7 days’ – Contrived Chaos & The Department of Health

UnknownI read recently an interview that Mr Hunt, Secretary of State for Health, gave to a newspaper. The problem, as they called it, is that nobody in Downing Street ‘expected the BMA…to sabotage’ the Conservative’s ‘7 day NHS’ election manifesto. This is certainly not true. In the run up to the general election the British Medical Association (BMA) launched their own ‘No More Games’ campaign with the sole aim of pleading with our political leaders to desist from using our NHS as a political football. Following on from this, they repeatedly asked the Government for clarity with respect to what their reputed ‘plans’ for a ‘truly’ seven day NHS were. Mr Hunt famously referred to his plans as many as eighteen times in one speech and in August when plans had yet to materialise, Dr Mark Porter, Chair of the BMA, took out a entire page newspaper advert simply to ask the question ‘When will the Prime Minister define what he means when by a ‘truly seven day NHS’?. I think if we can safely assume anything, it’s that Downing street absolutely had the foresight to know that discontent was coming.

The conflation of contract proposals with plans for a ‘7 day service’ continues however to be deeply distressing for junior doctors. On the day the BMA strike ballot result was announced, Mr Hunt actually gave an entire interview to ITV news while hardly referring to any of the junior contract issues at all (if you don’t believe me, read it). He repeatedly talks about having more doctors at the weekend; without any plans to actually employ more doctors. In one interview he went as far as to say that the proposals would mean more consultants at the weekend. Which is of course impossible, given we are talking about contract for junior doctors alone. He repeatedly talks about statistical excess in deaths as if they were de facto ‘preventable deaths’; a pitfall which Sir Bruce Keogh himself warned him against. It seems that the longer the junior contract row depends on the media, the more likely it is to be engulfed by 7 day service rhetoric. Genuine negotiations are required to give the BMA a chance to unravel the spin.

To add further to this frustration of course, when Mr Hunt does actually talk about the proposals, he dresses up a firmly neutral pay envelope as an 11% pay rise and talks of ‘perverse incentives’ to work outside rostered hours. If you ask a doctor what their incentive to work longer hours are, they will tell you it comes down to a sick patient in front of them and a regard patient safety is not perverse.

Some might say that the Conservative party had no intention of ever defining what their great plans were and how they would be funded. Now of course they feel obliged to deliver something and conflating the issue of junior doctor contracts with the ‘7 day service’ hot potato is rather a convenient scape goat. If they promise a contract that doctors know is unfair and unsafe, it is a doctor’s duty to resist it. If they make the public believe the junior doctor contract proposals are actually the answer to their mythical ‘7 day service’ then perhaps they won’t have to find the money to deliver something that works. Realistically of course, given the £2.2 billion pound deficit expected at the end of this year alone, can they be expected to find the money at all? In the end, junior doctors will be seen as resisting service improvements that weren’t existent to begin with.

Scrolling through the interview further, it is hard not to notice that Mr Hunt is described as ‘savaging’forcing’ and ‘lambasting’ junior doctors. I don’t expect that Mr Hunt has attributed these words to himself, but any reflective leader would surely be disappointed to hear himself described in these terms. The same article goes on to refer to the ‘cajones’ of our male secretary of state of health, while calling his female junior doctor adversary a ‘cheerleader’, but I think that’s a topic for a entirely different day.