Blood on the Tracks

When David Cameron and health secretary Jeremy Hunt refuse to listen to the pleas of just about every doctor and patient safety expert worth listening to, you have to ask why. The Academy of Medical Royal Colleges (the AMRC) – which represents all of the 22 medical royal colleges and faculties – is the latest to urge the government to suspend imposition of the junior doctors’ contract and return to negotiation as the BMA is keen to do, but Hunt is not for listening. ‘That train has now left the station. The matter is now closed.’ Although it clearly isn’t.

Either Hunt and Cameron are living out the conspiracy that the NHS must be irreversibly harmed to break it up for a sell off. Or they refuse to be beaten by the BMA whatever the cost to patients. Or they’re in denial about the fact that the NHS has run out of time and money to recruit, train and pay sufficient staff to provide compassionate, competent care around the clock. Staff are already working dangerous hours to cope with vacancies, rota gaps and record demand, and the service is only just held together by altruism and good will. So to prolong an avoidable war with doctors in training represents one of the greatest acts of political idiocy in the history of the NHS.

The AMRC describes an ‘unprecedented crisis’ and is also against the all-out strike planned by the BMA for April 26-27, which includes withdrawal of emergency care. This will be covered by consultants, non-trainee doctors, nurses and trainees who don’t support an all-out strike, or who will come in if the consultants can’t cope with the demand. If the government still refuses to listen, the BMA could escalate to an indefinite strike, probably scheduled after the European referendum. Hunt is supporting Cameron and his job looks safe until June 23 unless serious patient harm occurs during a strike, which would also harm the BMA and could lesson public support for doctors. If Cameron wins, he may yet replace Hunt with – say – Michael Gove or Boris Johnson as a punishment. Few politicians get out of the NHS alive.

Hunt has at least published his proposed imposed contract, which has allowed the legal action to start. The BMA’s legal challenge over the government’s failure to undertake a timely EIA (equality impact assessment) is likely to be swatted away, although the EIA made interesting reading when it appeared with the final terms and conditions on March 31. The government admits that features of its contract may ‘disadvantage’ and ‘impact disproportionately’ on women, particularly those working part time, but believes it is lawful and ‘comfortably justified’ as a proportionate means of achieving the legitimate aim of ‘a truly seven day NHS’ – whatever that is. The majority of trainee doctors are women and many may simply refuse to work under a discriminatory contract.

Many male doctors (MD included) also end up working part time in the NHS because the workload is so unremitting it simply isn’t safe for them or their patients to practice full time in the long term. Many full time staff put in over 80 hours a week, part time can be 30-40 hours. The stress can be unremitting and tired doctors make mistakes. Most believe they can’t be stretched more thinly than they are by the new contract. MD and the Patients’ Association are supporting the more widespread legal challenge of Just Health, an independent group of NHS workers committed to a publically owned NHS. It crowd sourced £100,000 in donations in 4 days for a challenge by Bindmans LLP.

Bindmans has sent a 41 page letter before claim to Hunt arguing that he has no legal power to impose a contract on most junior doctors as he is not their employer. For the minority of those he can be said to employ (who work in non-Foundation Trust hospitals), he did not consult with relevant parties prior to announcing imposition. And the decision itself is legally flawed and will not achieve the aim of a 7 day NHS. Bindmans have also sent a letter to NHS Employers advising them they may seek an injunction to restrain them from recommending the contract whilst its legality is being challenged. The contract includes a clause 22 that would allow Hunt and NHS Employers at their ‘absolute discretion’ to ‘review, revise, amend or replace any term or condition of this contract and introduce new policies and procedures, in order to reflect and respond to the changing needs or requirements of the NHS.’ Clause 22 is a catch 22. Sign the contract and sign away control over your terms and conditions. Don’t sign it and don’t work in the NHS. Small wonder applications for junior doctor training schemes are at an all-time low, and applications for certification to work abroad are at an all-time high. Thousands of treatments have been cancelled but the public remains broadly supportive of junior doctors. It seems only the High Court or blood on the tracks can stop Hunt’s train. Serious patient harm would also derail the BMA. And yet all this harm could be avoided by returning to negotiations. It’s utter madness.

Mind the Rota Gaps

The NHS is facing a £30 billion black hole in its finances by 2020, caused by 10 years if flat-line funding and a 4% year on year increase in demand for its services as people persist in living longer that they used to. Prior to the last election, NHS England chief Simons Stevens said – in the best case scenario – the NHS could recoup £22 billion in efficiency savings without damaging patient care, something MD (amongst many others) said was highly unlikely. This would leave the government with just £8 billion extra to provide over £5 years, enough to just about keep the lights on. Lib Dem expenses expert David Laws is now alleging Stevens asked for £16 billion from the government and was sent packing. True or false, the NHS is now being sucked into a huge black hole of debt and services and waiting times are suffering.

The demand on the NHS is made worse by 20% cuts in social care as patients can’t be discharged from hospital or stay well outside it. Poverty causes ill health too, and cuts in welfare payments add to the burden on the NHS. A sure sign the NHS isn’t coping is the chaos at its front door. General practice has faced huge funding cuts and is short of at least 5,000 GPs in England. But there aren’t enough doctors wanting to be GPs even if there was the money to pay them. Cameron made an inane manifesto pledge that ‘everyone over 75 will see a GP on the same day if they need to’, when in fact anyone should be able to see a GP when they need to. But with a dire shortage of GPs, many can’t.

The knock on effect on emergency departments is equally alarming. The emergency medicine workload is so unremitting that it has the greatest attrition rate of any medical specialty in the NHS, with almost 50% of year three and four registrars resigning. Dr Clifford Mann, president of the Royal College of Emergency Medicine, has warned of ‘unprecedented levels of pressure, overcrowding and a desperate shortage of medics’, with 20% of posts unfilled. He has asked for doctors from other specialties to be diverted to A&E to keep the public safe. ‘There have been some reports to harm to patients, and a collapse in the morale and resilience of the medical and nursing staff.’

The lack of safe staffing levels for nurses was a key finding of the Mid Staffs review, and NICE were given the task of gathering the best evidence for the safest ratios of patients to nurses in different healthcare settings, with the intention of moving onto other staff groups. Alarmingly, this work was pulled by the government and NHS England, who then tried to bury NICE’s finding before being forced to publish them under FOI. It seems the government wasn’t prepared to commit the funding to safe staffing, making a mockery of its manifesto promise to make the NHS the safest health system in the world. So many nurses are left caring for more than eight very sick patients at once.

Unsafe staffing levels are clearly bad for patients, but so stressful for staff having to cover rota and shift gaps that they either give up themselves after a few years, or decide that part time working is all they can cope with. In the annual census for the Royal College of Physicians, 21% of respondents said that gaps in the trainee rotas were so frequent ‘such that they cause significant problems for patient safety’. This problem is greatest for specialties that provide emergency cover for the NHS. Further up the ladder, the picture is equally bleak. Across the UK 40% of advertised consultant appointments could not be filled. Almost all were due to there being a lack of trained applicants, and many jobs attracted no applicants at all. Vacancies are most acute in the North West and West Midlands.

Ever determined to balance the books in the impossible hope of making £22 billion efficiency savings, the government has capped the rates of NHS locum pay, and locums are simply refusing to do the most stressful jobs for less money. Hospitals have now been forced to reduce medical cover on wards at night and reduce training for junior doctors. Out of hours care is flying by the seat of its pants and the government knows it simply doesn’t have the staff for its fantasy pledge of an extended ‘truly 7 day NHS’ even if it was able to bully the junior doctors into submission. Which it can’t.

As with every other policy in the NHS, workforce planning is driven by the need to save money, not what patients need. Despite the challenges of an ageing population, the NHS is training 19 per cent fewer nurses in 2014-15 than it was in 2004-05. Unsurprisingly, there was a 25% growth above inflation in temporary and agency costs between 2013-14 and 2014-2015. The solution is to train and retain more staff, not spread the existing staff thinner until they break. The National Audit Office found that in 2014, the NHS in England was short of 50,000 clinical staff. The latest estimate is a shortfall of 70,000 clinical staff. The twin obsessions of austerity and profitability will only make this worse. Far from being the safest health service in the world by 2020, the NHS is fast becoming the least safely staffed.

MD is performing at the Edinburgh Fringe and is supporting an independent legal review of the imposed contract.  We all need to know if Jeremy Hunt’s actions are safe and legal.