Thoughts on the junior doctors dispute…

I’ve watched the junior doctors contract debate unfold with sadness, dismay and a sense of frustration. Improving the quality and consistency of NHS care across all days of the week is a laudable aim that both NHS staff and patients support. So why has this debate become so polarised and acrimonious?

The BMA have accused Hunt of smearing junior doctors, misrepresenting academic studies and singling out junior doctors as the cause of excess weekend mortality. They have argued that the new contract is unsafe and that delivering a seven day service with existing numbers of staff will stretch services further and impact on the safety of weekday services. The mantra from the BMA has been that junior doctors already work seven days and to imply that they don’t undermines their professionalism and is a slur against their dedication to their patients.

These arguments are difficult to reconcile with either a considered read of the new contract proposals or the context in which the dispute has taken place. Whilst there is always a danger in the interpretation of studies (no doubt there are some big lessons here for the government), these arguments miss the point: no one disputes that there is now clear evidence that mortality rates for patients admitted to hospitals are higher at weekends. It would surely be wrong for any government aware of this not to act. However, the claim that junior doctors have been singled out as being solely responsible simply isn’t the case. To quote Bruce Keogh:

“The issue is complex with no single causative factor or solution. To tackle the problem we have developed 10 clinical standards, based on evidence and consensus. They seek to improve the availability of diagnostic tests at weekends, the availability of senior doctors to interpret and act on those tests and the provision of support services to enable the right treatment in a timely fashion. So this is not just about doctors, it is about teams and facilities.”

If the government strategy to improve weekend care was solely based on a new junior doctors contract, the BMA would be right to view this as cynical and unworkable, but this is evidently not the case. The contract changes for junior doctors are just part of a range of changes needed.

Similarly, it is hard to reconcile claims by the BMA that the new contract is unsafe with any considered view of the contract itself. The new contract reduces the maximum hours junior doctors are permitted to work and therefore provides more protection for patients against the risks of over-tired doctors than currently is the case.

The government’s chief negotiator, Sir David Dalton has recently said that commentary on social media has been ‘unhelpful’ during the negotiations. With comments such as “…we won’t let patient safety come crashing to the ground” tweeted from the BMA’s official Twitter account, it’s easy to understand his point. Is it really feasible that someone with Sir David’s reputation for safety would support a contract that increased risks for patients?

Similarly, saying over and over again that junior doctors already work seven days a week also misses the point. Of course junior doctors already work some weekends: the issue is one of system design. No one would design from scratch a seven day service with a large differential in pay rates on certain days. It is far better to remove adverse system incentives by reducing this differential, compensating with an increase in overall pay rates across all days.

Another argument often heard is that trying to achieve a seven days service with existing staff will impact on weekday services. But is the situation really this simple? A seven day NHS will still care for and treat the same number of patients but will be able to do so closer to their point of need. More patients admitted over a weekend will receive the diagnostic tests and treatment nearer the time of admission, meaning earlier discharges, less pressure and demand during the week and no backlog clogging up the system on Mondays.

There is currently understandable concern about financial pressure and the impact on safe staffing levels. The government’s decision to shelve the NICE work on safe staffing has only added to this, but again, the situation is not straightforward. The contact time staff have with patients is also important and the government are right to look at how this can be improved in the context of safe staffing overall

Largely as a consequence of reforms this government have implemented, there are now far fewer hiding places for unsafe care. There has been a push for more data and transparency regarding staffing levels, as well as changes to increase the independence and robustness of regulation. This includes a major focus during CQC inspections on ensuring that staffing levels and skill mix meets the needs of patients. In addition, the government has supported the establishment of a new independent patient safety investigations body which, when operational, would highlight staffing issues if they were contributory factors in the patient safety issues under investigation.

These are not changes that a government disingenuous about patient safety would make. As a consequence of its own reforms, any significant trend in adverse outcomes relating to inadequate staffing levels will now be more visible than ever before. If the strategy was to squeeze staffing to below safe levels these changes would make no sense. It would be akin to trying to encourage motorists to speed whilst simultaneously increasing the number of speed cameras

So how have we got here? It is in my view telling that David Dalton said in a recent HSJ interview that “…the BMA was not serious about negotiating a deal.” Do we now call Sir David’s integrity into question as well as Hunt’s, or could there actually be some truth in what he is saying?

The negotiations have been taking place at a time when morale in the NHS in low. Junior doctors are bright, hardworking people who chose a career in medicine because of a desire to save lives and make a difference. We need a system that nurtures and properly rewards them. If the currently system is failing to do this more needs to be done. But surely the junior doctor’s contract is the wrong battle, fought for the wrong reasons

Over the weekend a doctor sent me a direct message on Twitter which read

“I don’t understand the contract antipathy but very difficult to speak out against. I think very few have actually studied the offers.”

My fear is that the ‘offer’ itself ceased being the central issue in this fight some time ago.
In a recent Twitter exchange, the issue of junior doctors referring to their intellect during discussions came up. One junior doctor commented

“…I can’t apologise for having excelled academically no more than a sprinter should for being good.”

And of course, no junior doctor should have to. The challenges to improving patient safety and culture within the NHS remain huge. Too often still, the NHS responds to avoidable harm defensively and in a culture where the prevailing emotion is fear. The consequences of this are that the same mistakes are sometimes repeated and learning doesn’t happen, or when it does, those lessons are confined locally and not shared across the system. The NHS has an unfortunate history of burying its bad news, rather than facing up to problems and taking action to make things better.

To quote Bruce Keogh again:

“The transparent provision of data and information to the public is one of our strongest drivers for promoting quality in healthcare. But the use of data to promote quality also exposes some inconvenient truths.”

The only way we stand a chance of truly making lasting change is if patients, politicians and NHS staff work together. We must never go back to the days of burying inconvenient truths. The energy, passion and intellect of junior doctors are badly needed if these challenges are going to be overcome.

Johann Malawana recently tweeted

“…If NHS leaders…don’t value juniors & support imposition there are consequences.”

It would be tragic if these ‘consequences’ included yet more disruption for vulnerable patients and the derailment of further much needed changes to improve patient safety and save lives.

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2 thoughts on “Thoughts on the junior doctors dispute…

  1. JTO

    “…I can’t apologise for having excelled academically no more than a sprinter should for being good.”

    Not all ‘sprinters’ are ‘ good’.

    Perhaps he excelled academically at sciences.

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  2. Dr Derek Randles

    Sir,
    You speak with a great deal of wisdom on many issues raised here. I have a couple of issues which tarnish this and blemish it somewhat. Firstly, you fail to support your document with your name, and declaration of interests, merely ‘patient safety first’. Secondly, it is heavily biased, and that is a little amateur for PatientSafetyFirst. It has the feel of government dogma, and of course the links must be acknowledged.
    Overall though, good work – it is about teams and facilities. However, you miss important aspects on the value of the people in the teams. That is what makes them safe and makes them complex. As is so often the case the understanding of the whole ‘Human Factors’ picture is only partially understood or interpreted. This is not all about money (although I must correct you here, you do have to pay a little more for antisocial work – it is undoubtedly tiring, believe me).
    Money is not the major driver for doctors until they feel devalued. Offer (not force on) them responsibility and respect and you will be utilising some of the best minds in the country. Minds mixed with compassion. You can’t buy that, and you certainly can’t buy it back.
    However, I can’t help feel that the time for the advice ‘be careful’ has passed…

    None of us can escape from the fact that many of the very intelligent ideas from Mr Keogh, (I exclude Mr Hunt due to a lamentable lack of skill in the issue I’m afraid.), must inevitably have financial consequences. That is difficult in the face of chronic underinvestment. Well done on trying, but the hardline will inevitably fail.
    The Bhutanese utilise the Gross National Happiness currency. We should adopt it before making a decision. Patients will then feel safer when they join us.

    I welcome your response.

    Dr Derek Randles

    (Conflict of interest – I currently practice as a Consultant Anaesthetist who won’t be moving to Australia in the near future).

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