Chaining doctors to their jobs is no fix for the NHS

I was unsettled to read Tom Tugendhat MP’s recent article in the Telegraph. He suggests that we could resolve the doctor recruitment crisis in the UK by forcing doctors to work for NHS for a set amount of years after they qualify, to ‘pay back their debt to society’ instead of having the option of emigrating.

This is a very short-sighted solution, with multiple flaws. I don’t know how much exposure Mr Tugendhat has had to medical professionals, but if he’s had only a little he must surely be aware of the following:

The most obvious drawback to his plan is that it doesn’t do anything to solve the root problems which are making our doctors leave in droves. Surely remedying the pressurised workplaces, cuts to services and insulting contract prospects which are driving emigration in the first place would be a more logical (and kinder) step? Without these improvements doctors will continue to leave even if it has to be at the end of a period of enforced working.

Then there’s the fact that it would destroy what’s left of our morale. Doctors will stoically grind out hour after hour of work on the deck of the proverbial Titanic as long as patients benefit, but handcuffing us to a railing will only make us lose faith in the captain.

Furthermore, those of us that struggle with the inevitable strains of medical work, as so many of us do, will feel compelled to carry on, burning themselves out so badly that they won’t be able to work again for years.

And those that want to leave for Australia, or New Zealand, or wherever, but have been forced to stay, aren’t exactly going to be employee of the month, are they?

Another reason – patients will wonder if their doctor has been forced to stay. They won’t trust doctor’s motives as much, which is hugely important to us.

But it doesn’t stop there. Sixth formers won’t look at the prospect of a few years enforced labour for a flagging NHS at the end of their degree as an incentive to apply for medicine, especially those from lower income families who are watching student loans and the cost of living rise, but doctor’s wages falling. They’ll rightly think that leaving university with over £75,000 of debt entitles them to choose what they do with their degree.

There’s a philosophical point behind all this too. We don’t educate the young people of this country so they will give us something back. If we did, we’d be forcing teachers, scientists, lawyers and nurses to work for the state after graduation. But we don’t. We educate young people because education is a right, not one half of a deal.

Mr Tugendhat draws a comparison with the armed forces, who fund some medical students through university in exchange for a period of service after graduation. But this comparison is poor. The armed forces, essentially a third party, simply offers students lots of money in exchange for later work. The choice is about personal gain and is all theirs. Whereas NHS services that help train medical students already get paid for it by the state. Students pay loans to their universities for the privilege, have no choice but to train on NHS premises and their only gain is learning. Entirely different systems of motive. Maybe if the NHS started paying medical students tens of thousands of pounds in lump sums during their training, instead of them accruing massive debts, then we might be justified in forcing them to work for the NHS later on.

We should build a system in which young people study medicine and work for the NHS for their whole lives because it’s a great place to work, not chain our doctors to a sinking ship and think we’ve plugged the leaks.

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Why the new junior doctor contract is a slap in the face

NHS Employers have announced that they’ll be forcing an insulting new contract on junior doctors. The BMA Junior Doctor Committee did try to negotiate with them, but talks broke down and last month the BMA decided that it couldn’t come back to the table when what was on offer was so demeaning.

The reaction from medical staff (and the general public) has been visceral. They’ve made it very clear that this new contract would be nothing less than a danger to patients and staff alike and a despicable slap on the face for junior doctors. An unofficial petition calling for strike action has already topped 30,000 signatures.

So why all the anger? Here’s why.

  1. It’s a huge pay cut

From the limited data that NHS Employers have provided about the new rates of pay, most models, including my own, are predicting around a 10-15% pay cut. Although the new deal is supposed to be cost-neutral, we find it hard to trust a Health Secretary who denied nurses their 1% pay rise but then accepted a 10% pay rise himself, and who said that mental health funding had gone up despite mountains of stats that said that it had plummeted. Doctors don’t tend to be greedy people, but almost all of them have massive student loans, many of them have a family to support, and lots of them are trying, somehow, to afford a house. Seeing NHS Employers recently advertise for 200 ‘physician associates’, who only need two years training, for salaries of £50,000 a year, didn’t help our self-esteem.

2. It turns our evenings and weekends into ‘standard working time’

Currently, 7am to 7pm Monday to Friday is seen as standard working hours, and any work done outside of that is seen as worthy of extra pay. This seems reasonable. But the new contract extends these standard hours to 7am to 10pm on weekdays and Saturday, meaning that we’ll be paid the same for an hour of work on 9pm on Saturday compared to an hour of work at 9am on Tuesday. Only Sundays and nights are paid more. This means hospitals can rota us to work far more unsocial hours than we currently do at no extra cost, which is basically theft of our personal lives. Though doctors are frequently needed out of business hours, there’s no reason why we should submit to being paid the same for working at that time. We signed up to help people, not to sacrifice any semblance of a life outside of medicine as a favour.

3. There are no clear safeguards on monitoring our hours

Not so long ago, junior doctors were working over 100 hours a week. It was relentless, traumatic, and frankly dangerous. Then, after years of lobbying, the European Working Time Directive was passed into law and gradually the average number of weekly hours we were allowed to work started to shrink. It’s currently 48. A complex process of ‘banding’ occurs to add on a percentage amount to our basic salary (typically 40%) to recognise how hard we work out-of-hours and another complex process of hours monitoring occurs to make sure we don’t work too many hours. There are big incentives for employers not to overwork their doctors.

But with the new contract, there is no such system of monitoring. Doctors will be expected to go to their employers and ask for a ‘work review’ if they’re worried about their hours, which they won’t do because they’re too busy, which they’ll feel bad about doing, and which they’ll be quietly punished for doing. Back to the 1980s.

4. The reason for change – Cameron’s ‘7 day NHS’ – is deeply flawed

The whole point of this new contract is that David Cameron wants a ‘7 day NHS’. But he refuses to define what that means. He refuses to acknowledge that the NHS already works 7 days a week, and that forcing doctors to work more weekends and nights isn’t necessarily going to help improve services. Though Jeremy Hunt likes to spout about death rates being raised for patients admitted on the weekend, it’s still not clear if those patients just happen to be sicker or if more weekend doctors would save any of them, let alone be value for money.

I am seriously worried that doctors are going to be forced into rotas which schedule them for ever-increasing amounts of weekend and night work, with no clear rationale for what they’re meant to be doing, and no great means of doing it (as many other services are closed at the weekends). Some specialties like psychiatry don’t have a huge call for out-of-hours work, so pulling doctors from their Monday to Friday jobs to man the hospital on weekends would only be counterproductive. And we know that GP patients don’t necessarily love weekend appointments – pilots had to be stopped early as no one booked a slot!

5. Annual pay progression is being scrapped

In the clearest demonstration of how little NHS Emplyers and the DoH know about medical training, they’ve decided that instead of getting an annual pay rise, certain grades of doctor (SHOs, registrars etc.) should all earn the same amount within their grade, no matter how long they’ve been in that grade, as they all have the same responsibility. This is horseshit.

Every doctor knows that a first year SHO is going to be calling their seniors a lot, needing more help, and working slower. But a more senior SHO will be running more of the show for themselves, and helping out their less senior colleagues more, so deserving more money.

Also, pay progression encourages people to stay in their jobs, which at a time when GP recruitment is shockingly low, is a good thing.

6. It mistakes non-residential on call hours for lazing about

The new rate for non-residential on call hours (being at home, but available), is just 5% more than a standard hour’s work. As if doctors who have to rush in from home at 4am to do procedures that only they can do are of no use, when in fact, doing such on calls is often hectic, grueling and vital. And again, specialties who don’t have a huge demand for residential out-of-hours work, like my own, will suffer disproportionately.

7. It discriminates against women and men who want a family life

Currently, if a junior doctor changes specialty part-way through their training, effectively starting again, they stay on the same rung of the pay ladder to recognise their past service to the NHS. But under the new contract, pay will revert back to the lowest rate if the doctor decides to retrain in another specialty, or become an academic. Apart from being a harsh punishment for anyone who simply decides that they want to change their career direction (how dare they?), this is a flagrant swipe at women and men who want family lives, who often retrain in specialties more suited to that end, like GP or psychiatry. As if the fact that stopping annual pay progression will disproportionately hit women who work part time, as pay rises will come every 6 years instead of every 2, wasn’t bad enough.

I can’t emphasize enough how harmful this new contract will be for junior doctors and patients alike. Masses of my friends have already left for Australia, and they aren’t coming back. Why would they? The powers that be treat our NHS staff like dirt and unless we stop it soon, there won’t be anything left to protect.

I’m still undecided about strike action. If you could guarantee me that it would have a positive effect, then I’d be the first on the picket lines to fight for patient safety in the long-term. But the ignorance and deafness that NHS Employers and the DoH have shown is becoming legendary, so we may need another option. I’m open to suggestions. Help.

What the research on hospital death rates really says

There’s a been a big media splash today about research which shows an increase in the chance of death if you’re admitted to hospital over the weekend, compared to during the week.

Most of it has been reasonably accurate and clear, like the Guardian piece. But some has been misleading, like this Telegraph piece which states that you’re ‘twice as likely’ to die if admitted at the weekend, which seems to be nothing short of fictional.

The actual research paper can be found here [subscription required]. So what does it actually say, in simple terms?

The researchers looked at just under 15 million UK hospital admissions for 2013-14, of which around 280,000 led to death.

They worked out that the chances of a patient dying within 30 days of being admitted were 10% higher if they were admitted on a Saturday and 15% higher if they were admitted on a Sunday, compared to if they were admitted during the week. This sounds pretty damning, and frankly scary.

But it’s more complicated than that.

The first thing to note is that these numbers are what we call relative risks, i.e. the difference in risk compared to the same risk for another group of people. Relative risks can sound impressive, and they make for good headlines.

But the absolute risk of dying if admitted to hospital, i.e. the risk all by itself, is very small. Overall it was 1.8%, rising to roughly 1.98% for Saturday admissions and 2.07% for Sunday admissions. Not such a punchy headline anymore.

The researchers were also well aware that patients who are admitted over the weekend are sicker to start with. In fact, 50% of Saturday and 65% of Sunday admissions were emergencies, compared to 29% during the week.

The researchers did try to correct for this problem. They reanalysed their data after excluding all patients who died within 3 days of being admitted, to try to limit the impact that emergency admission had on the results. The relative risk of dying if admitted at the weekend dropped – to a 7% increase for Saturday admissions and a 10% increase for Sunday admissions.

As the study itself points out, we should be seriously cautious about interpreting these numbers, especially when it comes to blaming them on staff who prefer a ‘Monday to Friday’ working culture, as Jeremy Hunt is so keen to do.

Simply excluding everyone who dies within 3 days of admission isn’t a great way of excluding all emergencies. As any doctor (or friend, or relative) will tell you, many severely unwell patients don’t die as soon as they reach hospital. Modern medicine can support them for days if not weeks, so they could still be contributing to that increased weekend admission death rate.

Furthermore, during my days as a general medical doctor, it was routine to see patients admitted at the weekend not as critical emergencies, but as the result of deteriorating slowly over the previous few days, not being able to see a GP on a Friday, and eventually ending up in the option of last resort, an A+E bed on a Sunday, in worse shape than if their issue had started on a Monday. There’s a real case for poor access to other services being the real cause of increased weekend admission deaths, not a ‘Monday to Friday’ culture in hospitals.

This tallies with the fact that Saturday admissions do better than Sunday admissions – because they’ve only had to survive one day’s deterioration without their GP before coming into hospital, not two. If poor care in hospitals was really the problem, we’d expect Saturday admissions – who’d have to spend two whole days in hospital over the weekend – to do worse. But they don’t.

It’s important to note that no more deaths actually occurred on weekend days compared to weekdays. Weekend staff seem to be doing an amazing job of keeping people alive once they make it to hospital.

Another thing that any doctor will tell you is that care in the first few days of an admission isn’t likely to be much different if you’re admitted on a weekend compared to a weekday. A+Es and medical assessment units – the first two stops during most admissions – routinely have as many staff on at the weekends as during the week, and urgent tests and procedures still happen quickly. It’s only when a patient has been moved on to a general ward, maybe 2 or 3 days later, that they might feel the effects of the weekend slow-down, as routine investigations have to wait. This doesn’t tally with staffing factors being the cause of increased weekend admission deaths.

Don’t misunderstand me; doctors couldn’t be keener to ensure that patients get good care on every day of the week. Contrary to popular belief, only 1% of consultants opt out of weekend working. And I’d never deny that junior doctors can feel overworked and undersupported at the weekends, meaning that there is room for improvement in senior doctor hours.

But we have to understand what statistics really mean before using them as the basis for policy and contract changes which will profoundly affect our health service for decades to come. To assume that the increased death rate for weekend admissions is preventable, in the words on the researchers themselves, would be ‘rash and misleading’. Take note Mr Hunt.

We already have a 7-day NHS. Don’t believe the hype.

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