April 26th. 2015
Someone will die in hospital as the junior doctors’ strike today and Wednesday. In fact about 1,200 patients will die on each day because, for better or worse, hospital is where most people do die. Expect an attempt to seek out a grieving family ready to blame the strikers: that’s the risk the British Medical Association takes.
But emergency or maternity patients may not be put at great risk as consultants abandon their “cold surgery” lists to take over emergencies. Their waiting lists will lengthen even more as people in pain wait longer, but emergency patients will be getting good care from these most skilled doctors: some of their younger colleagues in training are often flying blind, in a secret state of panic.
A future indefinite strike is another matter: are both camps ready to keep raising the stakes? With each side shroud-waving, the juniors claim the imposed contract“puts patients at risk”, while Jeremy Hunt, the health secretary, rattles spurious statistics on weekend death rates. But the government has fatally damaged its case with a flat refusal to consider a sensible cross-party compromise, supported even by the Daily Mail and Sunday Times, to set up pilot schemes to test if the contract does reduce weekend death rates.
Dismissing the plan with a rude tweet, Hunt and David Cameron expect to beat the doctors into submission – treating this as their “miners’ strike moment”. Give in now, they reckon, and the whole public sector will follow. But if the government does impose this contract, they may find it a very pyrrhic victory: winning a battle but igniting a public sector war.
Consultants are hugely supportive of their juniors, with presidents of 10 royal colleges sending a last-minute plea to Cameron to return to the table, for fear of “demoralising a group of staff on whom the future of the NHS depends”. They and the nurses now fear conflict over Cameron’s seven-day NHS manifesto pledge, promised without a penny extra to implement it. As with all public employees, after long years of a freeze any pay rise is capped at just 1%, while national average pay rose over 3% last year. The NHS and local government have only survived austere cuts by this unprecedented real cut in public sector pay. The lid can’t stay on that pressure cooker for 10 years.
A strike ballot of ambulance paramedics was called yesterday by Unison’s Dave Prentis, who claimed that Hunt had reneged on a promise to upgrade their pay and conditions. But this is only part of the NHS issue, as gaping staff shortages add to the strain of coping with fast rising numbers of older patients. Hunt blundered in picking on the juniors first, already working long hours.
Take Dr Ellen McCourt, a junior in the emergency ward of a North Yorkshire hospital, who works one in every two and a half weekends. We spoke as she began her 13-hour Saturday shift, to be followed by 13 hours on Sunday. The new contract will make her work every other weekend and cut her pay: “I love what I do in emergency, the variety of cases, working with the sickest patients when you can help them most.” But she’s a rarity: recruiting to emergency medicine is notoriously hard; on every shift she finds at least a fifth of doctors’ slots unfilled. “There was a very good locum this weekend, but he’s leaving for Canada.”
As she came off duty on Sunday evening, she described the weekend: 45 patients all the time, with 10-15 waiting to come into the ward. A 90-year-old with pneumonia, a young diabetic in a bad way, someone with blood clots on the chest. One patient came in to die: “The nurses juggled people round so she got a private room. She needed medication to see she wasn’t breathless, anxious, in pain or distress. She wanted to talk about dying, she needed time.”
She marvels at how many teams flocked to one emergency – the respiratory, the intensive care and the crash teams, each with their own consultants: “And they say doctors aren’t there at weekends!” She came off duty hardly knowing if it was night or day, having picked up a bad cold. No rest yesterday as she headed down to London for the vigil outside Hunt’s office.
To bring these doctors out for the first time in decades has taken unprecedented provocation. Cameron threw in the “seven-day NHS pledge” without costing or defining it. No 10 says it means seven-day GPs – but GPs are struggling to cope as it is. NHS England says it only means emergency work – knowing it’s already there. Hunt yesterday withdrew his previous idea that it meant round-the-clock elective surgery – phenomenally expensive.
All this is justified by alarming reports of “11,000 extra weekend deaths” – but that figure has been exposed, not least by the editor of the BMJ pointing to research suggesting that nursing and diagnostic staff matters most. More people admitted Friday to Monday do die – but no one knows how many or why. The King’s Fund began work on the phenomenon but gave up, according to Candace Imison, then the fund’s director of policy, now at the Nuffield Trust. Should they look at those admitted at weekends, or dying at weekends? How do you compute the different types and numbers of weekend admissions? How do you discover why? Professor Martin McKee wrote in the BMJ that the money needed to save one life under seven-day working would save more lives elsewhere.
Money matters in life-saving, as trusts’ debts rise higher than ever. Hunt has threatened trust boards with the sack if they don’t clear their debts without reducing quality, but that’s an impossibility. The unfunded seven-day working pledge comes on top of a Treasury demand that the NHS “save” £22bn – another impossibility. The Care Quality Commission, itself cut by the Treasury, is raising the cost of its brutal inspections, making its victims pay. What a time to provoke NHS staff.
Senior NHS managers regard Hunt as a dead man walking, who will be gone in the post-referendum reshuffle. But Cameron is as much to blame for this calamity, so will the next minister sent in continue this pointless confrontation? What the NHS needs is someone to navigate gently through these multiple crises, stop provoking staff and be willing to arm-wrestle new money out of the Treasury. God forbid the NHS will be inflicted with another eager politician hoping to make their name with yet another Big New NHS Idea.