Last weekend, 20,000 junior doctors from across the country marched in protest at the proposed changes to their contracts. It's becoming increasingly clear from the press coverage and the softening of the Governments stance, that they are realising the battle for this is not going the Department of Health's way. Suddenly on the day of the protest, the rhetoric changed. It moved from being all about patient safety, to being about how junior doctors were being deliberately misled by their union, the BMA. Jeremy Hunt said in an interview on BBC Radio 4's Today programme that "the BMA has misrepresented the government's position. It's caused a huge amount of anger unnecessarily; we don't want to cut the pay going to junior doctors".
Given that a huge part of training to be a doctor is about learning how to assess data, how to interpret evidence, how to cut through misleading headlines, it was a bit of a ridiculous line to take. Does he think doctors are easily misled? Does he think the junior doctors haven't all read the proposals themselves? It was a bit sad to witness this poorly thought-out line fall flat, with a rapid twitter response #Istandwithjohann (Dr Johann Malawana, Chair of the BMA Junior Doctors Committee leading the negotiations) and when the 20,000 protesters were asked to raise their hands if the BMA was representing, and not misleading them, every hand was raised. Awkward Jeremy....
What should the Junior doctors and the public expect next? What will the next tactic be? I'm not a junior doctor. I am a qualified GP and have been for the last 8 years. But I remember those long shifts, the overwhelming responsibility. I remember the physical and emotional strain. I remember sitting in the admissions unit at the end of a gruelling 90 hour week of nights, staring at the heart tracing in front of me from a patient with chest pain. It was 4am and I was so tired I couldn't even focus on it. I remember curling up on the floor under a quiet stairwell to try and get 10 minutes of rest. I remember one occasion I almost fainted because I hadn't eaten all shift; when I went to get some toast and sit down for 5 minutes, the cardiac arrest bleep sounded. I was consumed with guilt that if I had stayed on the ward, I would have been there quicker to try and save the patient. I was a junior doctor under the system currently in place. The system with financial penalties when hospitals breached the maximum hours. There are tricks to get round those maximums, and while we could report these breaches, it didn't help the patient at the time and it didn't suddenly create extra doctors to cover the rota. There are even fewer doctors now.
I like to help Jeremy Hunt occasionally. Bless him, he needs it. So to save another flop of his usual spin like the BMA one, I've jotted down a few lines he should avoid over the next few weeks.
"This contract simply formalises what junior doctors are already doing."
Well, yes and no. Junior doctors are regularly working over their contracted hours, so it formalises it in that sense. But that isn't a good thing. You want to formalise it, reduce the pay, and remove the system in place that fines hospitals if their junior doctors work beyond a safe number of hours. The reason these fines were brought in, is that when there was no financial penalty, the hospitals all ignored the limits on hours. You must realise that in a hospital, with sick patients coming in, there will always be some give on hours. Junior doctors will not simply down tools halfway through an emergency operation and declare "I'm off home now - good luck!" But equally the work ethic that stops this happening is so easily taken advantage of. Especially in a system under stress, when there aren't enough doctors. What you say is "This new contract simply formalises what is already happening". What junior doctors hear is "I don't care enough about patient safety and your individual fitness to practice to keep these safeguards in place. I know that means you will get abused, but I don't care."
"The government must address the issue of more deaths at the weekend."
No, the government mustn't address this. Because the evidence at the moment is rubbish. To try not to get bogged down in statistics, let me give a simple analogy.
You buy a ticket for the lottery. You know the chances of winning aren't great. In fact they are millions to one. Your chance of winning is almost zero.
So you decide to DOUBLE YOUR CHANCES!!! Amazing! You're sure to win now, right?
No. Because all you did is buy one more ticket. Technically you've doubled your chances, and that sounds great. But in reality the chance of you winning is still infinitesimally small. It's now a tiny tiny bit above almost zero.
Time for some numbers - the research that Jeremy Hunt keeps talking about shows that Monday-Friday, there is a 1.32% absolute risk of death (so a 98.68% chance of NOT dying in hospital). At the weekend this goes up to 1.53% risk of death - a 98.47% chance of NOT dying in hospital at the weekend. Yes, it is a bigger risk. But it's a bigger risk that is still a TINY number. The other thing Jeremy hasn't mentioned, is that this study looked at patients both in hospital and for 30 days after they left hospital. Almost half of the deaths happened after the patient had been sent home. The authors of the research paper haven't fully explained how they worked all of this out - which is generally a bad sign. They also haven't explained why the death rate on a Sunday is actually less than on a Wednesday. Jeremy didn't mention that bit did he. I didn't see any headlines about "Deadly Wednesday". It is also highest on a Friday, when there are full emergency and routine services running. Confusing isn't it? That's one of the reasons that an author of the research said that assuming any increase in deaths seen could be prevented would be "rash and misleading". Not exactly a vote of confidence in Jeremy's interpretation.
What the government should be doing is not scaring the public into thinking they will die if they get admitted at the weekend. It should be reassuring them there is plenty of emergency and urgent care by doctors of all levels available 24/7 in the NHS. And if it really wants to pursue this, it should do so with a high quality study in a totally open and transparent way.
"Doctors in this country get paid well compared to similar roles in other countries"
Yes, but we're not in other countries are we? We are in this country. So let's look at how much it costs to train a doctor, how much debt that doctor leaves university with, how much it costs them to carry on their training, how much the cost of living is, and base pay on that. If doctors all over the world earned £1 million pounds a year, would that be a reason to pay our NHS doctors the same? No, of course it wouldn't. Hospital specialists in the UK earn an average of £79k. In Germany, it's £105k; the Netherlands £158k; Australia £212k; America is £256k. So why use this pointless comparison apart from as another way of reinforcing the message that all doctors are rich and lazy? When you've trained and worked as a junior doctor Jeremy, then feel free to make that call.
"It's the managers' fault. They aren't making sure there are enough doctors in the right places when hospitals need them. This contract solves that."
No. It doesn't. The managers stick within the hours legally set for their junior doctors. If they go outside this, the hospital gets fined. If they can't fill the hours the hospital needs, it's because there aren't enough doctors. They then face a choice - employ locums to cover the shifts, or push doctors to cover and risk a fine. This contract removes the safeguards, so implementing it means there is nothing to stop managers making their own doctors work those long, dangerous, currently illegal hours. It will save money on locums. But the real issue is there are not enough doctors to provide the service. Here's a novel idea - how about training some more? The best way to start is to show some appreciation for the ones you already have.
There are my top tips Jeremy. Feel free to ring if you need anymore. That's the thing about us NHS doctors. We are here to help people. Even you.