What next for junior doctors?

The first junior doctors’ strike in 40 years could be the making or the breaking of the NHS. The optimistic view is that the bravery of junior doctors in speaking up in such numbers will inspire all frontline staff to find their voice, expose the spin, tell the truth and get involved in improving the NHS. The NHS is unusual in that it has so few clinicians in senior management, and yet the best hospitals globally tend to be run by clinicians. The less optimistic view is that doctors are being de-professionalised to line them up as employees in a more corporatised NHS, and that the breakdown in trust between this government and the frontline is irreversible. Applications to medical school dropped by 11% in 2015, and also fell in the two years prior. 52% of junior doctors who finish foundation years currently take a break from NHS training and some will never return. If too many ditch the NHS, its future will indeed be bleak.

Many doctors have lost all trust in health secretary Jeremy Hunt to present data accurately and fairly (Eyes passim), and they simply don’t believe that more NHS services can be extended over 7 days with the same number of staff and no extra money without making the staff work longer or harder for the same money or less. In a recession, many employees are expected to work harder and longer for no more money, but the NHS is a ‘safety critical industry’ and many frontline staff are already working full throttle. To make them work harder would be bad for their mental health and dangerous for patients.

Hunt has asked Sir David Dalton, chief executive of Salford Royal NHS foundation trust, to enter the fray and broker a deal between the BMA’s Junior Doctors Committee and NHS Employers. Dalton has the advantage of running a highly regarded hospital that has managed to provide excellent 7 day urgent and emergency services using the existing junior doctors’ contract. However, it has not extended its 7 day routine services as Hunt and David Cameron seem to have suggested (Eye …). On the downside for some doctors, Dalton lead a review of the NHS that suggested concessions for companies who took contracts to operate publicly funded hospitals and that a single private or public organisation could own and operate chains of hospitals across wide geographical areas.

Dalton, and all NHS staff, realise that junior doctors’ working conditions and the government’s ‘promise’ of 7 day services can’t be seen out of context of wider problems in an NHS and social care system facing an unprecedented 10 year funding squeeze. As one junior doctor I spoke to put it: ‘The problem is not just lack of doctors, it’s lack of nurses and support staff and the fact that the hospitals and emergency departments are already full so we couldn’t do more routine work anyway at weekends. Even if we could, we have nowhere to discharge patients to in the community. On my last on call in paediatrics there was one registrar and one senior house officer looking after 22 cots on the Neonatal Intensive Care Unit with very sick babies in them, and also covering all the labour ward emergencies and post-natal wards. To help we had just three band 5 nurses and one healthcare assistant. It was a nightmare and clearly isn’t safely staffed, but the government refuses to publish all the evidence on safe-staffing. I end up having to do ECG’s (heart tracings) on call as there is no ECG technician and it takes me ages figuring out how to work the different machines. When I work out my total hours, many unpaid, I get less than the living wage. But what helped was when a senior manager spotted how hard I’d worked and said thank you.’

Another doctor added: ‘If the NHS wants to keep its doctors and nurses, it needs safer staffing levels, shorter shifts, more breaks, healthy meals and study leave paid for. But above all it has to inspire and value them. It doesn’t need a macho tit of a health secretary who seems incapable of telling the truth and enjoys confrontation. It just alienates and angers us all, and makes us suspicious he’s trying to soften us up for a sell off.’ The government and the BMA will eventually reach a very dull, detailed and disappointing settlement. But the anger and passion of the junior doctors must be welcomed and harnessed before it’s allowed to escape to the Antipodes. Hunt claims that the NHS needs whislteblowers and now he has 53,000 more of them. All he has to do is shut up and listen.

MD’s book, Staying Alive – How to Get the Best from the NHS – is available here

Healthy Mind, Healthy Body

Why is the physical health of those with mental illness so poor? A study published by the Nuffield Trust and Health Foundation in October found that those with mental ill health have almost five times more emergency hospital admissions compared to those without. And yet the vast majority of these emergency admissions were for physical health problems.

Despite the government’s promise of ‘parity of esteem’ for mental and physical illnesses, those with mental illness have much higher rates of physical illness and struggle to get adequate help for both their mental and physical health problems. Hence, far too many mentally ill patients end up in emergency departments and prison cells. And there are clear links between austerity and the increased number of male suicides since 2008.

Research by the King’s Fund published in November found that 40 per cent of mental health trusts had their income cut in 2013/14 and 2014/15, despite rising demand. To reduce costs, many trusts are trying to shift patients away from acute services to ‘recovery-based care and self-management programs’ that sound good on paper but don’t always have a solid evidence-base, don’t have the resources to get them up and running aren’t being properly evaluated. Despite these changes, in the year up to 2014/15 there was a 23 % increase in patients being hospitalised far from home, bed occupancy rates routinely exceeded recommended safe levels and only 14 per cent of patients say they received ‘appropriate care in a crisis’.

Without stable funding and proper evaluation of new services, the outlook for mental health services and the people who rely on them looks bleak. And the challenge of improving the physical health of those with mental illness needs urgent attention. The main cause of early death in those with mental ill health has for many years been untreated or poorly treated physical illnesses. Deaths from causes related to mental ill health, such as suicide, account for under one third of the total.

People with serious mental ill health die on average 10 to 17 years earlier. For people with psychoses, the under-75 mortality rate is more than three times higher than in the general population. And yet the commonest causes of premature death are heart, lung, liver and kidney diseases, obesity, stroke and diabetes.

Forty-six per cent of people with a mental illness also have a chronic physical illness, compared to 30% in the general population, and all of the main chronic physical conditions occur at higher rates for those with severe mental illnesses. The conditions that most commonly lead to premature death include respiratory disease and diseases of the digestive system, which are four times higher in mental health service users compared to the general population. Deaths from circulatory diseases are two and a half times higher.

The reasons for this are complex – it’s hard enough overcoming the stigma of mental illness and seeking help, and to have disabling physical illnesses too makes it even harder. Most GPs still have 10 minute appointment slots that make it impossible to properly assess those with such complex problems. Accessing any treatment when you’re feeling confused, anxious and unwell isn’t easy – travel, parking, finding your way around poorly signposted NHS buildings. Anti-psychotic medications can have side effects that make drowsiness, mobility and confusion worse. The answer may well be to offer outreach or home services to patients who need them most – education, lifestyle coaching, monitoring – but these are expensive. And yet the alternative – waiting for avoidable illnesses to become emergency hospital admissions – is even more so.

The division of illness into mental and physical is in itself divisive. All illnesses have mental and physical causes and consequences, and both need treating together. As Dr Geraldine Strathdee, National Clinical Director for Mental Health at NHS England, puts it ‘It is the major distress caused by untreated or inadequately treated illness that can lead to people finding a way to ‘anaethetise’ their distress.’

MD’s book, Staying Alive – How to Get the Best from the NHS – is available here
Letters in Response

Sir,

I was pleased to see MD draw attention to the problem of the poor physical health of people with mental illness. They are more likely to have respiratory conditions such as chronic obstructive pulmonary disease (COPD) as well as cardiovascular disease and are more likely to die prematurely because of these conditions. A key driver of this is high rates of smoking – 40% to 50% in people with depressive and anxiety disorders and 70% in people with schizophrenia. The Royal College of Physicians 2013 report “Smoking and mental health” noted that 2 out of 5 of all cigarettes smoked in the UK were smoked by someone with a mental health problem.

A great deal of scientific ingenuity has gone into making cigarettes as addictive as possible, but the evidence is that people with mental health problems are just as likely to be able to quit smoking successfully if provided with appropriate support. Unfortunately, the Government’s decision to cut £200 million from public health funding is now being translated directly into cuts in smoking cessation services across the country. This is damaging one of the highest value interventions that the NHS provides and will impact severely on the most vulnerable in society, driving further inequality.

Without attention to the causes of reduced life expectancy in the mentally ill the concept of “parity of esteem” for mental illness is simply a platitude.

Dr Nicholas Hopkinson MA PhD FRCP @COPDdoc

Reader in Respiratory Medicine

Imperial College London

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Sent: 08 January 2016 12:53
To: Strobes
Subject: MD 8th Jan

One of the main reasons that mental health patients have poorer health, is that nicotine counteracts the sedating effects of anti psychotic medications, illustrated by the fact that smokers are simply titrated larger quantities of the drugs to counteract the stimulus of nicotine; a vicious circle. This is why there are still smoking areas in psychiatric units, as to ban them would probably lead to a riot.

Peter Nightingale

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Sent: 09 January 2016 12:15
To: Strobes
Subject: Letter regarding Medicine Balls, Eye 1409

Dear Strobes

I am disappointed that MD seems unaware that some of the measures he proposes to tackle ill health in those deemed mentally ill – education, lifestyle coaching – are in fact the very measures that underpin the “recovery” approach to mental healthcare. He is critical of the recovery approach, and echoes Marjory Wallace’s criticism of its lack of an evidence base. Yet behind the appallingly high rates of physical ill health in those deemed mentally ill lies the fact that psychiatric medications need only undergo very short randomised controlled trials in order to be licenced for prescription. These short trials fail to demonstrate what we now know about many of these drugs: long-term use of them causes cardiovascular problems, metabolic problems and weight gain, leading to much premature yet preventable mortality. While MD is correct in that stigma is part of the cause of the inflated levels of preventable deaths in those deemed mentally ill, he seems to be ignoring the fact that many of these deaths are treatment induced. “Evidence-based medicine” as currently practised sometimes seems to ignore important facts.

With kind regards

Michael Ashman MPH DipHE