On Course for Disaster

I was one of ten thousand people who marched on Westminster to protest against the unjust and unsafe imposition of a new deal for junior doctors by an arrogant government. The reforms treated us like cogs in a malfunctioning machine, abolishing our autonomy and any consideration for family life. We cheered as the leader of the opposition spoke up for us, told us how much the NHS meant to him, and explained how the government had got it wrong by undervaluing junior doctors. The year was 2007, and the speaker was David Cameron.

Last month, 98 per cent of junior doctors (on a 76 per cent turnout) voted to strike not over pay – only a small minority would lose out – but over the imposition of a contract that would have removed important safeguards on how many hours junior doctors can work and extended ‘standard time’ to 7 a.m. to 10 p.m., Monday to Saturday (instead of 7 a.m. to 7 p.m. Monday to Friday). It would have disadvantaged the doctors who currently work in the most demanding specialities in terms of weekend care, discriminated against women with children and penalised medical research.

The health secretary initially seemed to favour a fight. The line the press obligingly regurgitated was that he would be ‘deeply muscular’. The breaking of the miners’ strike was invoked. But on 30 November, hours before the first strike was due to begin, Jeremy Hunt made a beleaguered statement to the House of Commons. He suspended his threat to impose the new contract unilaterally, and accordingly the BMA agreed to suspend industrial action.

It’s as well the strikes were averted. Junior doctors gave hospitals much more notice than is required by law so that appropriate measures could be put in place, but delays in non-emergency care could have led to patients suffering serious harm, as consultants would have had to cancel elective work to make sure emergencies were adequately covered. However, nearly all doctors agree the imposition of the contract would have caused more patient harm than temporary withdrawal of labour. Calling the strikes was a last resort.

Hunt has said repeatedly that he was elected to provide a seven-days-a-week NHS. There’s a lack of clarity about what this means: the latest assurances from the Department of Health suggest the commitment refers to emergency care, not elective work. It’s unclear just how bad the ‘weekend problem’ is, but one thing’s for certain: it isn’t due to a lack of junior doctors. A shortage of diagnostic services at the weekend can be a real problem, and a lack of social care means it’s often difficult to discharge elderly patients. Junior doctors are the people most responsible for delivering weekend care, so they should be the constituency most in favour of the new approach Hunt thinks he’s bringing in. That they aren’t is the surest sign that the approach is flawed.

In the dying days of the Blair administration, a series of reforms euphemistically known as ‘Modernising Medical Careers’ were pushed through. They replaced an apprenticeship model of training – doctors working in small, stable, tight-knit teams – with a centralised and highly bureaucratic model, under which doctors advance by gaining ‘competencies’ based on a series of (literally) tick-box exercises. It’s these reforms, as much as the threatened new contract, that are the cause of low morale among junior doctors. Despite Cameron’s oratory, and savage criticism from the official report, successive Conservative-led governments haven’t revised the model.

There are some causes for optimism. It’s very good news that strikes have – for now – been called off. There has also been a marked improvement in the performance of the BMA. In 2007, it was lavishly upholstered but highly ineffective; it aided and abetted disastrous reforms despite overwhelming opposition from its junior members. This has changed: the BMA is handling the negotiations reasonably well, and is now seen to be robustly defending junior doctors. That said, many are extremely angry that the BMA backed down over strikes, and it remains to be seen if it can continue to command its junior members’ confidence.

The grounds for pessimism are more secure. It’s difficult to see how Hunt can regain any trust, and if the BMA does cut a deal – any deal – in the few short weeks each side has agreed to talk without threats, there is every chance that it won’t be accepted by junior doctors. The result of that could be mass resignations. Retention of junior staff is already at an all-time low, with nearly half of all doctors who complete their first two years now not progressing to the next stage, preferring instead to move abroad or switch careers. (There’s a silver lining for the Australian medical system, not to mention management consultancies and banks.)

At the moment, we are on course for disaster. The threat of strike has been lifted only for six weeks, and there’s little prospect of fundamental change in that time. Even if the Department of Health came forward with extra cash it wouldn’t solve the problem: it isn’t fundamentally about money, a difficult concept for some in government to understand. The underlying causes of discontent have to be addressed first. Prior to any new contract, there should be a thorough investigation of what’s wrong with the way junior doctors work, led by junior doctors themselves, with the support of consultants and other healthcare professionals: people who are used to working at speed under pressure, and who understand the problems first hand.