Doctors strike: what's all the fuss about?

From the point of view of an internet-generation junior doctor the level of awareness, anger and coverage of the DDRB contract proposals is overwhelming (DDRB is the Review Body on Doctors' and Dentists' Renumeration, advises the government on rates of pay). Years of frustration are finally being vented across social media sites and articulate and human arguments for fair working conditions and for the survival of the NHS are commonplace.

Until recently the discussion has been largely restricted to junior doctors themselves, various websites and forums becoming an echo chamber for doctors to agree with one another, preaching a familiar message to a choir who are already well aware of the issues and who are more than ready to reply with similar stories and personal perspectives, and occasionally this can breed an element of oversimplification, hysteria, or hyperbole, particularly as the issues are a little too complicated to be adequately summarised in a tweet or hashtag. However this hotpot of energy and anger is spilling over and is now beginning to be reported by the national mainstream media. There have been issues in expressing this anger in an understandable and constructive way but we are beginning to find a common voice. 

Manchester Picadilly Gardens last night- pic by Manchester junior Dr Jeremy Lyen

Last night I attended a march in central Manchester, forming part of a slightly smaller but no less passionate crowd than the 5,000 in London the previous evening. It was moving to see so many doctors and medical students united in the campaign, and it was excellent to see the support from the public. It marks the beginning of a campaign to make doctor’s issues well known, and to highlight the direct threat to patients and the NHS. Some form of industrial action in the next few weeks seems inevitable and it is absolutely essential that the public are aware of why doctors feel this is the only path forward. Without the backing of patients and the public any strike will further alienate and vilify doctors and pave the way for the profession and the NHS to be dismantled.

To that end I feel obligated to highlight some key points that may not be obvious to people outside of medicine. The grievances of doctors are multiple and complex so what follows is merely a heavily simplified personal take on the main issue – the BMA website is a good place to start for more details, or the facebook page of any junior doctor. I want to clarify 1) what a junior doctor is 2) why the contract is unfair for doctors and 3) why it is poisonous for patients and the NHS.

The BMA is the union that represents doctors in the UK, and took the uneasy decision (backed by members) to walk away from junior doctor contract negotiations after several discussions, realising that the proposals were neither safe nor fair, and were not a position from which an acceptable contract could be negotiated from. The government plan to impose this new contract on junior doctors in England (not Scotland or Wales) from August 2016. The current vocabulary is misleading, and poorly understood even by other medical staff including consultants. A “junior” doctor is a qualified graduate from medical school undertaking postgraduate training in hospitals or the community. The term includes the very bottom (yours truly) foundation doctors, but also any doctor in training that is not a consultant or GP. Virtually every doctor under 35-40 will be a junior doctor. The label “junior” sticks even if you are in your ST8 year of surgery training or have taken time out of the training programme for example to do research, change specialty or do voluntary work. It is very likely to be a “junior” doctor that performs your elective surgery or resuscitates you in A+E or sees you in clinic. These doctors, from new “juniors” (F1) to experienced “juniors” (senior registrars), make up about 40% of all doctors working in the country and all stand to suffer at the hand of new contract changes.

The contract fundamentally changes the way doctors are paid. People may need medical attention at any time of the day and on any day of the week. The NHS is straining but it is providing a 7 day service 24 hours a day. The current government has allowed misinformation to be spread such that patients now fear hospitals at the weekend. At present junior doctors receive a basic salary that rises with experience, and receive a supplement on top of this if their rota involves a lot of night shifts or weekend work. The new contract redefines “social” hours” as 7am-10pm six days a week, so rotas involving working evenings and/or all day Saturday would attract no increase in pay compared to a  9-5. The new contract would increase the basic pay but slash the unsocial work supplement such that doctors working in more acute specialties (already unenvied and overworked doctors such as in A+E, hospital medicine or ITU) may end up with a 15-40% pay cut whilst doctors with more normal hours may have a modest increase - but are at risk of seeing their rotas suddenly becoming much more antisocial without increase in pay. Almost every recommendation of the DDRB contract proposal is worse for junior doctors, and is therefore directly toxic to the NHS as a whole.

It would be dishonest to suggest that a strike is “not about the pay”, because no sane person would be willing to accept such a pay cut – particularly not if they had already been silently suffering a pay freeze/de-facto pay cut for several years (15% less than 2007 in real terms). The current system also does not seem to recognise the increased amount of unpaid overtime (>5hrs/week on average), self funded training, BMA/GMC/royal college membership costs, compulsory medical insurance, spiraling university debt (36K for 4 years tuition alone), or essential, expensive and difficult postgraduate exams. The public perception remains that doctors are well paid, and the well-heeled, golf-playing, Mercedes-driving doctor is a persistent one. This cliche is probably true for a small minority, especially a small number of hard working and very experienced consultants that may supplement their NHS income with private practice. But it is not true of the current generations of doctors in training.  In truth junior doctors at the moment are paid more than the average UK worker, and pay does increase with experience.  There have been several unhelpful comparisons of doctors with the perceived circumstances of other workers. In my opinion it does not help to compare with tube drivers, retail workers, McDonald's managers or physicians associates, as these workers have their own grievances and are of course also entitled to fair pay. Such comparisons serve only to perpetuate the idea that doctors are self-important and entitled: we stand to alienate ourselves from other professionals and the public, many of whom will (unfortunately for us) remain unconvinced that a junior doctor in their 20s or 30s is deserving of a salary that approximates their age in £K, no matter how many bleeding heart "open letter" accounts of their jobs they might read.

The wider issue however is the future of the NHS. In the short term patient safety is likely to be compromised as doctors working longer hours for less pay will be tired and demoralised. There will be more burn out and more mistakes. In the longer term these doctors will continue to leave the NHS in England. There is already a recruitment crisis in several specialties including GP and A+E. 20-50% of training positions in GP and A+E remain unfilled, yet somehow the government expects to attract even more doctors to these careers by making the job less satisfying and reducing the pay. About 60% of FY2s (second year post medical school) last year took a year or more out of training for various reasons and that number is sure to grow as more and more juniors are either forced out of the profession as they can no longer afford childcare or mortgage repayments, or realise that enough is enough; their skills and training are appreciated to a far greater extent outside of the NHS, outside of England or outside of the profession itself. NHS workers have been leaned on already. If the doctors don't stand up to the changes and fold then I am sure the bosses will go for other professionals. The NHS is suffering an insidious end by a  thousand cuts. If the contract is implemented as it is currently I foresee a slow and sad cycle of positive feedback as for each doctor that leaves the NHS leaves a slightly less tolerable atmosphere and workload for those remaining. Morale gets lower and patients are harmed, expensive locum and agency staff are required to fill the gaps and eventually the public will be led to conclude that the NHS has run its course and must be rescued by the private sector. 

I am deeply saddened that this is the situation I have found myself in after years of medical school and only two months in the job. It is a treasured privilege to work as a junior doctor and I am immensely proud to work for the NHS. And because I value both of these things I will be voting alongside thousands of my colleagues in favour of industrial action to protest these contract changes.

One more junior's voice

So many people have taken to the internet to express a lot of what I am about to reiterate too. Much of it is written with greater thought, clarity and passion than I can hope to here. But there is no defense in omitting such an important topic from my so-called blog. A few plagiarised images will have to suffice in trying to express these concerns.

I really have no idea what the general public know or think about what is happening to the NHS as I type this. All of my professional contacts and a large proportion of my personal ones work for the NHS in one way or another, and each of them feel similarly numb and impotent and downhearted by the situation we find ourselves in. The current handling of the NHS via its funding, organisation and staffing very directly affects me and the people I know. But it also directly affects every single NHS user as chronic underfunding of services and maltreatment staff will inevitably lead to cracks that will continue to erode the service and endanger patients.

I spent 4 years at medical school, and 7 years at university in total. Clearly it wasn’t a particularly efficient way of gaining employability, but even the most decisive school leaver must spend a minimum of 5 years as a student before they qualify as a doctor – and current students now pay £9,000 per year for the tuition fees alone. As a recent graduate I might spend ten or more years as a junior doctor, but even if I were to choose the fastest possible path, and succeed at every hurdle along the way, they would need to spend at least five years before becoming a GP or consultant.

Not even two months into this journey the government brutalise the system by pushing through a contract universally opposed, representing a long list of kicks not least of which is an expected 10-40% pay cut for trainee doctors. This takes junior doctor pay to pre-2000 levels and is a near-fatal blow to the morales of staff throughout the country. Furthermore the contract redefines "social working hours" to include 7am-10pm, 6 days a week. The BMA, with backing from doctors, made it clear that this was unacceptable and were unable to negotiate from here but the contract will be rolled out from Aug 2016 regardless.

 This is not the way I expected to start the career I had waited so long to begin; feeling betrayed, undervalued and impotent. We feel we deserve to be treated better, and it is this that is ominous for the future of the NHS. Even before this recent revelation I was well aware that there are far far more attractive employment opportunities for doctors outside of the UK, most foundation doctors I’ve spoken to had entertained the idea of leaving the NHS, either for a few years or permanently .There is a current retention crisis; doctors are choosing to retire earlier or change careers, and there are unfilled training posts in several key specialties including GP and A+E. As things stand these problems can only be significantly worsened in years to come. Understaffing is already a huge problem, with gaps only superficially filled with expensive locum and agency staff. The cycle is bleak:  inadequate staffing causes increased stress and mistakes, the service is less satisfying for staff and patients and so more doctors drop out of the game.

I do a small amount of e-mentoring for prospective medicine applicants, and I am quite often a source of information and advice for applying friends and family or work experience students at hospital. I now feel that it would be dishonest to recommend this path for the nations bright, optimistic and dedicated students. There are certainly other careers that pay far better, careers where you might feel respected or valued, and possibly even where you might have a better chance at a work-life balance.

This is a very good account about the situation, from the point of view of an ITU trainee doctor, and another excellent one here from an A+E trainee.

According to the BMA it costs about £260,000 to train an FY1 doctor, and a further £300,000 to train them to consultant level. New doctors will now find it difficult to even pay off their loans. It simply does not make sense in my head to invest so deeply in training medical staff only to be apparently unconcerned when many of them feel they have no option but leave the NHS. To me it sends a message that there is no concern for the future of the NHS, it seems that consciously or not the NHS is being set up to fail so that in the not-too distant future we are led to believe that the NHS is an unworkable idea  and privatisation is the only solution.

The level of outrage amongst staff, both junior and senior, medical and non, has been visceral and overwhelming. We share a keen sense of injustice but are struggling to find a constructive voice. Today my facebook wall is alive with righteous anger, though the audience reached may often be mostly other junior doctors. We cannot sleepwalk towards deeply unfair, short sighted and dangerous reforms and I will begin by joining many others in writing to my MP. It seems clear to me that a well funded and well functioning health service (available to all) is of vital importance to a nation, and a workforce that is present without resentment is essential for this. It is a message that I have no confidence that Jeremy Hunt has heard, and we are becoming exasperated at his continued inability to understand the issues surrounding healthcare delivery, and his continued refusal to hear the concerns of the public or the professions.  Clearly the recent petition re a vote of no confidence achieved very little despite overwhelming support (220,000 signatures and Mr Hunt did not attend the debate). I am concerned that the collective voice of doctors in the UK will continue to be ignored and some sort of strike action becomes unavoidable. I doubt this can be achieved without alienating the public or putting patients in harm’s way but there is far too much at stake to do nothing.

Some background and media coverage
http://www.bma.org.uk/working-for-change/in-depth-junior-and-consultant-contract/junior-doctor-contract-negotiations-home

http://www.independent.co.uk/voices/comment/i-dont-blame-doctors-for-walking-out-of-pay-negotiations-with-the-government-10506483.html

http://www.theguardian.com/society/2015/sep/18/junior-doctors-new-contract-cut-pay-40-per-cent

http://www.telegraph.co.uk/news/health/news/11875628/Junior-doctors-threaten-strike-over-new-contracts.html

http://metro.co.uk/2015/09/20/doctors-are-being-pushed-to-strike-over-new-contracts-which-will-risk-patients-lives-5399640/

From the Facebook page of Dr Philip Lee MBBS MRCP(UK)(Geriatric Medicine)
Consultant Physician in Acute Medicine and Care of the Elderly

Nobody likes a complainer

Nobody likes a complainer, so I feel real sympathy for my friends and family who have listened to me moan about my job with astonishing regularity and passion over the past couple of months.

There are dozens of things that irk me about my job, and since it feels like I am at my job most of the time I feel irked most of the time, in dozens of ways.

What is difficult is that despite all of my complaining, most of my friends and family don’t really understand why I am so angry all of the time. So I can only conclude that 1) I am not at all good at articulating my gripes and 2) I am an unusually grumpy and furious sort of person.

There is good evidence for both 1) and 2), but I don’t think we can exclude the third possibility being true at the same time: 3) there are several problems with the job at present that are only acutely apparent to an fy1 in my position. So with that in mind I’ll power on ahead with some more complaining about a particular aspect of my job, mercifully in a highly ignorable way.

A broad category of irritation is prescribing; managing patient’s drug therapy is an important part of the role of junior doctors.

On my most recent night shift I got talking to a pleasant patient who refused to relinquish his usual tablets to the nurses for safekeeping. I was unable to convince him because I privately agreed that this was a pointless thing to do.

A patient in hospital is expected to hand over all of their regular medications to the nursing staff so they can lock them in a safe. A junior doctor is then asked to copy all of the drugs and doses onto a hospital drug card which instructs the nurses when, if and how to give each drug.

A pharmacist then checks that this has been done correctly, and alerts the junior doctor to any mistakes so he or she then can return to correct them. This is common because very junior doctors have only a small fraction of the drug expertise as the pharmacists, but only doctors can prescribe.

Even if a patient previously had complete control over when to take each drug, in hospital it is the nurses that administer the medication. The gentleman I was talking to protested that quite often on his previous admission he was left for long periods of time before being allowed his pain medication as the nurses were unable to attend to him immediately, because they have millions of other things to do.

When the space on the drug card runs out the junior doctor is then asked to copy out the drugs once again onto a fresh drug card. These re-writes would not be necessary if we adopted electronic prescribing.

http://www.polyp.org.uk/index.html

When a patient is well enough to be discharged from hospital the junior doctor must take the dug card to a computer and type them into a specific and ancient piece of user-hostile software in order to produce a printout of the patient’s list of drugs (the same drugs as on the drug card) to give to a pharmacist, who will check the list and dispense the drugs.

A pharmacist then checks that this has been done correctly, and alerts the junior doctor to any mistakes so he or she then can return to correct them. This is common because very junior doctors have only a small fraction of the drug expertise as the pharmacists, but only doctors can prescribe.

This prescribing process is required for every patient in hospital, even when their drugs are exactly the same before, during and after their hospital stay. It creates delays for patients receiving their drugs, requires the input of and communication between at least three different professionals and delays discharge from hospital, further contributing to the already pressing hospital-wide bed shortage.

A patient cannot be discharged until a doctor writes their discharge summary, and their medications are “prescribed” by a doctor. It falls to the junior doctor to write this summary even if they have never before met the patient. The doctor must also prescribe their drugs without expert knowledge of their condition, or management plan, or why they are even on the drugs, so often they are prescribing drugs simply because they were on them before admission. Such time-consuming paperwork never takes priority over more urgent jobs for unwell patients and so very often discharges are delayed, at great cost to the NHS. Some trusts employ “discharge locums”, doctors who are paid simply to ensure all of this paperwork is done and all these boxes are ticked to allow beds to be freed up. This isn’t an entirely satisfying solution but may be a pragmatic solution to the issue in the short term: on the same nightshift I was bleeped repeatedly to do some of these TTOs  (“to take out” medicines) left over from the day before, and I ended up doing the discharges when I had a spare minute away from more urgent tasks- at 8am the next morning.

Let me quickly insert dozens of caveats; I am not questioning any of the following:

I can see that there is value in having a clear record of a patient’s drug therapy before and during a hospital stay.

I can see that there is value in allowing nurses to control medications, especially when there are issues with a patient’s capacity to safely administer them himself. I can see that it might be important to store controlled drugs away securely to prevent them getting into the wrong hands.

I can see that experience in prescribing is an essential part of the training of doctors.

I can see that having a clear summary of what happened in hospital is important, and I can see why having an up-to-date list of medications and any changes is important for record keeping and to inform future management decisions.

But I am questioning all of the following:

I am questioning whether it is appropriate for a junior doctor (on-call or otherwise) to complete discharge paperwork for patients they’ve never met.

I am questioning whether it is a good use of resources to mandate that nurses dispense routine medications to competent patients.

I am questioning why it is necessary for the doctor to perform tasks that are then repeated and improved by a pharmacist.

I am questioning whether it is safe for junior doctors to write discharge summaries without clear instructions from senior doctors regarding future management or follow up.

I am questioning whether it is reasonable to expect discharge summaries to be completed between 2pm (end of ward round) and 5pm (closure of pharmacies) when there are a multitude of more important things to be done.

I am questioning the sense of using a paper based prescription system that is simply translated to an electronic one (via hideous software) upon discharge.

Of course, none of these problems would be quite so irksome had we either sufficient time or staff to perform the tasks to a satisfactory level without feeling rushed.