April 26th, 2016
There has always been a tension at the heart of medical practice as to whether it is a vocation or a job, between dedication to patients and to making money. It is, of course, a bit of both; and for a healthy and effective healthcare system, it is critically important to keep these two elements in balance. When the junior doctors first came out on strike I was opposed to their action (and said so, ). I was opposed because I thought they would lose public sympathy and trust – and this disaster may yet happen – and because I felt it was against their professional duty as doctors.
Although I still feel the junior doctors and British Medical Association have handled their public relations poorly, and were wrong to resort to strike action without a more effective PR campaign, I now support their continued action. It is a high-risk strategy because it is going to put great strain on the NHS, and the public and sections of the media may well not forgive them if patients come to serious harm because of the strike.
But I have changed my mind, for two reasons. First, it is overwhelmingly clear that the government is either blind or in a complete state of denial over thefinancial crisis that is developing in the NHS. The UK has fewer doctors per capita than any other country in Europe except for Poland and Romania; what an extraordinary time to fall out with them.
In terms of cost-effectiveness the NHS has always compared very well with other healthcare systems, and much of this has depended on the goodwill of its staff. After the sudden profligacy of Tony Blair and Gordon Brown we are back tospending less on healthcare as a proportion of gross national income than most other major European countries. I need not rehearse the well-known facts about the problems with community care, the ageing population and the ever-spiralling costs of medical technology (particularly in cancer care).
The public have not been told the truth about the funding crisis and have not been given any choice about paying more
The seven-day working week being promoted by the government, which is at the heart of the crisis with the junior doctors, is meaningless if it is not financed properly – and it quite clearly isn’t. Even the Economist, with its deep faith in markets, recently wrote that there was indeed a crisis, but then blamed it on “the British public”, who were unwilling to pay more for healthcare. This is unfair – there has been no admission from the government that there is a serious funding crisis, and that it needs to find new ways of making the public pay more for the healthcare they want.
The public have not been told the truth, and have not been given any choice. Instead, the government seems to think that competition and marketisation (which was the only consistent theme to Andrew Lansley’s chaotic NHS reforms) will be the philosopher’s stone that will resolve this problem.
It will not. Anyone who has worked, as I have done, in countries with commercial, competitive healthcare systems knows that competition puts costs up and never reduces them when all healthcare is included, and not just the easy, low-risk, profitable parts. Think of Hinchingbrooke hospital and the high hopes with which its privatisation was launched, until Circle Healthcare walked away from the contract blaming funding cuts.
It is also a sad fact that many doctors and healthcare providers are corrupted by profit-seeking. This is because patients are not informed consumers, are often vulnerable, and because so many potentially expensive medical decisions – such as when to treat, or how far to investigate – are not clear cut. Nor are they easily regulated even by excellent organizations such as NICE. Socialised healthcare, as the Americans call it, has many faults, but fewer than marketised healthcare – especially with regard to social equity.
I stopped full-time work for the NHS last year, and am currently working in Kathmandu, in Nepal. The second reason for my change of mind is a final-year English medical student who is attached to the hospital I work in. As we sat in an earthquake-damaged building in a remote valley where our hospital was doing charitable work, she told me of what she now faces on qualifying as a doctor.
The selection process is a nationwide, entirely impersonal process, in which she will have minimal choice as to where she gets a job; and it pays no attention to personal or family commitments. She will be treated more like an army conscript than a future professional responsible for patients’ lives. What shift-working junior doctors have to do has already led to the loss of a sense of belonging and respect that doctors, including me, had in the past. Continuity of patient care, and the deep satisfaction that came with it, has also disappeared.
By treating the junior doctors as just another group of assembly-line workers, and seeing medicine as just another business, and by denying the looming financial crisis in the NHS, the government and its hired management consultants have entirely destroyed that subtle balance between vocation and money at the heart of healthcare.
I now understand more fully than I did before why the junior doctors have become quite so desperate and demoralised. If patients come to harm as a result of this tragic strike, I would now put the blame firmly on Hunt’s and the government’s shoulders. The NHS is not safe in their hands.