It’s good to talk – are the BMA playing into Hunt’s hands?

The junior doctor contract pantomime has now been running for a few months, without much progress in the plot.

The BMA calling a strike ballot polarised what is a complex issue. Of course I voted yes-yes, because to vote no would have been tacit agreement with Hunt’s plans.

But that’s not to say that I’m in awe of the BMA’s positioning. Quite the opposite. They have found themselves up against a master politician in Jeremy Hunt, and they’re being quietly maneuvered into an ever-weaker position.

In summary, they withdrew from negotiations many months ago and state that they will only return to the table if the threat of a contract being imposed is lifted.

This makes Hunt’s life easy.

Firstly, it’s an unreasonable demand. The BMA can’t honestly expect him to agree that a contract should only be implemented when both parties agree on all aspects of it. This would effectively give the BMA a veto on everything and a license to make unlimited demands. It’s the employer’s prerogative to implement contracts. The employee’s prerogative is to strike if they don’t agree with the content, but not to strike about the possibility of them being imposed.

Secondly, it leaves him an ultra-easy rebuttal. He can just smile sweetly, ask us again very nicely to come and talk it over like adults and such an enforcement probably won’t be necessary. But if we refuse to talk, he’s oh-so-sorry but the great British public voted for a 7-day-NHS, so changes will have to be made without our help.

All our other demands, the genuine contractual concerns, are totally neutralised by Hunt waxing lyrical about his (minor) concessions so far and the fact that ‘anything is up for negotiation’ if we talk.

We will end up looking like we’re striking against the possibility that a contract might be enforced at some point in the future, while refusing to talk to the man who will have to, as is his right and only option if we refuse to meet with him, do just that. Which is frankly weird. And the public will not understand it.

Wouldn’t it be a better tactic to find a reason to return to negotiations that saves face (perhaps a huge strike mandate?) then use those negotiations to push Hunt, again and again, for the changes we so reasonably want?

This would give us the upper hand. Instead of looking sulky and unreasonable, we’d be giving Hunt a good, solid chance to refuse fair contractual compromises. The public could understand this. Then and only then would it be fully effective to strike.

If Hunt imposes a contract, fine. We can strike about that. And keep striking while negotiating, watching the heat slowly build around him as he refuses again and again to make compromises fair to one of the most trusted professions in the land.

If the BMA could add in some proactive PR – some widely-accessible soundbites on how Hunt’s demands will cause the weak, sick and vulnerable irrevocable damage due to thousands of doctors burning out or flying off to Oz, then all the better. We need to hammer home the narrative that doctors are the NHS, we are all the NHS, and how dare Hunt, that outsider, pick on us when we’re trying to look after eachother. We have to make it look like striking is our last resort to desperately protect those we love from a vicious swindling.

But right now, I’d just settle for standing on a picket line knowing that my representatives were talking to the man able to make changes to my situation – even if just to continually prove that he won’t budge.


No beds in the whole country – mental health services hit a new low

Two years ago, I posted a tweet that a lot of people found very worrying.


I hadn’t been working in mental health for long, and had been shocked to discover that often the local area, even if it was the capital city, would have no available inpatient beds. Patients would have to be sent out-of-area, often hundreds of miles away, to be admitted.

The Guardian asked me to write about it in more detail, which I did. We were hopeful that with all the publicity occurring at the time, things would change.

And since then, things have changed.

Now, they’re even worse.


I don’t usually talk online about my individual professional experiences. But recently, I found it hard to contain my frustration and sheer disappointment. Presented with a patient who needed a bed, there were none in the local area, none in the surrounding areas, and none in the private sector nationwide. Patients like this, wherever they present in the country, have no option but to wait in A+E, or at home, or in a police cell, until appropriate, safe care can be provided. Which is a disgrace.

Minister for Health Alistair Burt MP was quick to reply that my statement ‘was found to be untrue‘ – by which I think he meant that there were some beds available in the country, but probably in random Trusts, hundreds of miles away. Trusts have no practicable way of contacting every other Trust in the country to seek out the last open bed in the land, and even if they could, that Trust would likely be trying to protect it for their own patients. So not a particularly constructive response from the Minister (what would’ve been wrong with ‘tell me more about the problem?’).

I don’t want to dwell on the minutiae of my own particular situation. My patients and my Trust deserve their privacy as they fight their own respective battles. But it wasn’t an unusual situation for a UK mental health service. Norfolk and Suffolk have been the only Trust that I know of who’ve been brave enough to say it publicly, but not being able to find a bed in the whole country is the new baseline for ‘tricky weekend’ in mental health.

It’s not hard to see how we got here.

The government has tried bloody hard to convince us that funding in mental health is rising, but the numbers aren’t exactly shouting out that conclusion. Some sources say there could actually have been cuts of up to 8%, with Trusts forecasting the same cuts again over the next few years.

Even if you believe the government line, that there has been investment (which they don’t seem to be sure about themselves), it pales into insignificance as part of the bigger picture.

Mental health was drastically underfunded to start with, accruing just 13% of NHS funding, despite accounting for 23% of the ‘illness burden’. But now with austerity in full flow, way more people are in contact with mental health services than ever before. Our sister services, public health and social care, have been decimated, leaving us to pick up their slack.

The end result? Carnage. We’ve lost 17% of our beds in the last 3 years (5% in the last year alone). The amount we pay private hospitals to takes care of our patients, because our own beds are full, has doubled in the last year alone to a very conservative estimate of £38m. Out-of-area admissions rose 23% in the same period. Bed occupancy is 94% on average, with some Trusts working at over 100%. And we used the Mental Health Act 10% more this year than the previous year, as patients spiral into crisis and need to be compulsorily detained more often, into beds hundreds of miles away that they’re less likely to go to willingly.

The interim report of the Crisp Commission has shown us that we technically may have enough beds, it’s just that so many of them are taken up by people who could be discharged but have nowhere to go. Good health doesn’t happen due to health services alone, so to say you’ve ‘ring fenced’ the health budget while cutting social care funding is willful idiocy.

In a way, I wish the solution to this problem was more complicated than it really is. It would reassure me that our politicians are working hard to fix the problem, but haven’t been able to. But that’s not the case.

We need real funding. Not just for isolated interventions like perinatal, liaison or early intervention services that have robust cost-effectiveness evidence bases and slightly-flashier-than-average selling points, but for general services too. Not just for humane reasons, but to stop our patients burning through funds in other services (police, A+E, ambulances) without it doing anyone any good. Spending money on mental health saves money, and not funding us adequately creates an inefficient, shameful shambles.

We need not just well-meant documents like the Crisis Care Concordat, but to stop cutting nursing staff numbers (down 3,300 over the last 5 years) so there’s someone left to provide actual care.

And besides all that, we need to be incredibly wary of slick rhetoric from politicians about how mental health services are a key issue, without them giving detailed assurances – including significant funding amounts – that big changes are about to be made. Their talk is cheap, and increasingly so, your mental health treatment is too.

24 hours of admin in mental health services

I recently had a Twitter conversation with Geraldine Strathdee, our National Clinical Director for Mental Health, about the administrative burden we face while practicing in our specialty. She asked me to write a blog detailing just how much paperwork (and electronic paperwork) I have to do over a set period, to shine a light on the issue. So this might not be my most scintillating blog, but I’m hoping that it’ll create some useful discussion nonetheless.

I’m writing about a typical day in my current job, but none of the content is specific to my team or Trust. I’ve done six other jobs in mental health and they’ve all carried roughly the same weight and type of admin.

The day shift

I’ve been away for a week (typical lazy junior doctor), so I get in early to check through my emails. I answer a few of the more pressing ones, which if at all vaguely important need to be copied and pasted into the electronic notes. I make a few phone calls to patients who left messages last week, typing the entirety of the conversations up too.

Then I move on to seeing some patients. Two full assessments in the morning. Not only do both need extensive clinic letters but an array of auxiliary electronic forms need to be filled out too. Each new patient needs a diagnosis under the ‘Outcomes’ tab of their electronic notes and a full risk assessment under the ‘Risk’ tab (the form has around 100 optional tick-boxes as well as free text space). Also, HONOS and clustering scores need to be calculated (two multiple choice forms which take 2-10 minutes each), so we can demonstrate that our patients are ill enough to need our help. These are all individually fairly easy forms to fill out, but when you have to do 5 for every patient, it suffocates you. I perpetually wonder why I was never weighed down by all this when I worked in general medicine (it’s because Acute Trusts pay coders to extract the information from the notes after discharge and don’t have such an unhealthy obsession with ‘risk’).

I make some more phone calls at lunch time, followed by seeing two more patients in the afternoon. It’s the same admin story as the morning’s patients. I also remember that every meeting we have with a patient needs to be confirmed on the electronic notes diary, so it gets logged as work that the team has done. This involves clicking on the appointment under the relevant tab in their notes, then laboriously copying every bit of information about the appointment (who is going to be there, what time and date it’ll be, where it’ll be, what it’s for) from the left hand side of the page into identical boxes on the right hand side of the page, to confirm it all actually happened. For every appointment. If we don’t do it, the computer doesn’t recognise that we did any work.

I stay late to finish (some of) my clinic letters and write covering letters to three other services (two within my own Trust) who I’m referring the patients to. I email all the letters to the admin team, who are wonderful. They’ll print off the letters and send them in the post (yes, including to other services in our own Trust), where the recipients will most of the time scan them right back onto their own computers. Welcome to our ‘paperless’ NHS. It’s been no different in any Trust I’ve worked in. Occasionally I find replies from these services in my pigeonhole, sent by post as well, already scanned on to our own computers by the wonderful admin ladies, who frankly must have better things to do.

God forbid you ever want anything from a GP. They have to fax it across to you, for it to be scanned and the hard copy shredded. Often they even ask for a faxed request to prove that you’re really who you say you are. It’s 2015. Email was invented before plenty of doctors were even born.

The night shift

I finally manage to get home, but I’m on call, and after grabbing some dinner I’m called into A+E to help see some new patients. Not a process which is easy on your typing fingers. Every time we see a patient in A+E, we have to:

  • write an entry in the handwritten A+E notes
  • if the patient is new, open an electronic account for them before you can do any of the above, entering their name, address, phone number, NHS numbers, and GP details at a minimum.
  • On the electronic system, fill in a brief clinical note…
  • do a risk assessment…
  • calculate the HONOS and cluster scores…
  • enter a diagnosis…
  • write an assessment letter…
  • and do a covering letter to the GP for the assessment letter.

Plus whatever extra paperwork you need to do for that individual patient, for example, a referral to social services, psychological services, or an employment support service. I have to admit, it’s so much paperwork that it’s sometimes very difficult to enjoy seeing patients. Which is a HUGE warning sign. How much paperwork do orthopaedic surgeons do when they see a patient in A+E? (not just the depth of detail on the forms, but the amount of forms?).

After quietly tiptoeing out of A+E, I make it home for a nap. But in the early hours of the next day, I’m called out again to assess someone who has been brought in on a Section 136 by the police. I see them, and they need to come into hospital. And as is absolutely usual, there are no beds.

The phone calls begin- to the consultant, to wards who might be able to spare a bed, and inevitably to the bed manager and anyone else who needs to give the green light to an out-of-area bed. Every phone call is accompanied by a note on the electronic system, in addition to the assessment entry (and risk entry, etc. etc.) and the handwritten section paperwork. Thankfully an SHO is around to do the drug chart and the blood test forms. I email the patient’s usual care team to tell them what’s happened. Eventually a bed is found, and the transfer paperwork needs to be readied – so you’ve guessed it, everything needs to be printed off, and either faxed to the accepting hospital or put in an envelope with the patient.

And with that done I go home, get some ice on my typing fingers, and catch a few hours of sleep before the emails start rolling in again.

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