In their desperation to be heard, Junior Doctors in England started a sit-in outside the Department of Health this week. Visiting the site myself, it was clear that they are taking their protest very seriously and doing everything in their power to persuade the government to turn back the clock. It seems reasonable to accept their views as valid. They want the government to step back and think of a fairer and safer plan to implement their vision for 7 day NHS care, instead of forcing through a contract that remains unmodelled, uncosted and is likely to be understaffed. There remain serious doubts over whether the existing Junior Doctor workforce can suddenly expand their service and training commitments without any increase in their numbers. In fact, a recent example of a current rota for junior doctors shows that even existing rota gaps are considerable even before further stretching elective services over an extra 2 days.
Junior Doctors must feel like the first dominos in a chain reaction of inevitable NHS meltdown and workforce burnout that will soon involve consultants. It will not be long before Allied Health Professionals such as radiographers and physiotherapists may be compelled to follow suit in having their contracts changed to align with doctors. This system change has clearly not been given careful consideration in its piecemeal implementation. In fact, only last year, the Society of Radiographers published a scoping paper that looked at the implications of extending working hours, for consideration only and certainly not headstrong implementation.
So why has the government not done the same for the Junior Doctor Contract? It's probably because they thought that by wooing doctors by purported pay increased and reducing the maximum number of hours worked per week (both of which are more complex than the government would have us believe), there was then no need to explore different models of service delivery. A risky gambit indeed.
A recent debate hosted by the Nuffield Trust asked the question 'Are NHS services on the brink of fundamental change or collapse?' as part of their Daring to Ask series.
The most compelling speaker in this debate was undoubtedly Professor Keith McNeill, who pulled no punches. In an impassioned retort to this question during a separate interview,he put across his point with aplomb, saying:
"I believe that the NHS, and most health systems really, are always on the brink of some sort of change. Fundamental change? No.
What have we heard? The latest call is for more 'grip' on providers. More grip is going to do nothing but strangle the system even more than it is now.
There will be no fundamental change. There's still no extant leadership of the NHS. We're still over-burdened with bureaucracy, with regulation, with inspection, with commissioning that doesn't do what it should be doing. So, it depends on where you sit - but I can tell you as a clinician on the front line, that we are well over the brink of collapse".
This scathing attack of bureaucracy over fundamental change was echoed in his description of the NHS during the original debate as having 'more pilots than British Airways', referring to pilot projects that did not lead to meaningful system change.
It's all very well for the coffee house gossipers or Public House patrons to put the world to right about the NHS, but surely there is a Plan B or even a Plan C? Directing resources at preventing hospital admissions and increasing throughput may be a more fruitful approach to an NHS with fundamental change at its heart. Spending 18 years trying to introduce innovation into my own service to improve outcomes for older people with alcohol misuse has gone some way in addressing a sustainable prevention model. At the other end of in-patient pathway, we still have major problems in ensuring timely discharges to free up beds. Referring to his experience as CEO of Addenbrookes NHS Trust CEO, Professor McNeill again:
"When I was there - and just the other week - we had over one hundred delayed transfers of care (DTOCs) in the hospital. So we could be described as either a residential or full nursing home. We were looking after hundreds of people on a month-by-month basis, who could have been looked after more effectively in the community".
If a system is broken, trying to stretch it further for political gain appears foolhardy, especially if this is done through implementing change for a contract that will push junior doctors to breaking point. In the 1960s, during a similar time of economic austerity and associated dissatisfaction among junior doctors, 30-50% of the annual medical workforce emigrated to Australia and New Zealand. The same is likely to happen again if the Junior Doctor Contract is imposed. History has a way of repeating itself.
On May 3rd, under the auspices of the British Medical Association, there will be a meeting to discuss "the current healthcare crisis, plummeting morale in the medical workforce and the prospect of further risks to patient care in the future".
Jeremy Hunt maintains that "the train has now left the station" in precluding further negotiations over the Junior Doctor contract but its destination remains unknown and is clearly on a different track to one designed to improve patient care through the best use of resources.
There must be red light somewhere. If not, the Jeremy Hunt Express will surely be derailed through poor visibility.