For months, Conservative health secretary Jeremy Hunt has been locked in a bitter dispute with the British Medical Association (BMA) over his plan to impose a new contract for NHS junior doctors in England.
The BMA is a medical trade union that represents the national body of junior doctors, the overwhelming majority of whom deem the terms of the new contract to be both unsafe for patients and unfair for themselves.
Last December, junior doctors expressed their mass dissatisfaction with Hunt’s plans to impose the contract when 98 per cent of those who voted in a ballot for strike action elected to back said action as a means of encouraging their health minister to reach a safe and fair compromise.
Four strikes have already occurred under Hunt’s watch since January; each concluding without any agreement to end the impasse. A fifth strike, with clear majority-public support, is set to commence this morning; this one is an unprecedented “all-out” strike from 8AM to 5PM over the next two days.
2,500 extra consultants and senior doctors – the most experienced practitioners – will, however, provide emergency cover during the strike so as to ensure, notwithstanding irresponsible scaremongering in the establishment media, that lives and patient safety will not be put at any greater risk than normal. These consultants have too expressed their opposition to the contract and broadly support the action by their junior colleagues.
Whilst the resort to industrial action is not an ideal situation – it will admittedly inconvenience and disadvantage those who will have had non-emergency treatment postponed – junior doctors have been forced into this undesirable position by the obstinacy of their health minister. Striking in the hope of preventing the imposition of a contract that will compromise the interests of patients to a much greater degree in the long-term than the current strike ever will is a case of informed junior doctors making a considered choice of the lesser option of two evils.
The BMA has been clear for some time that the strikes will end as soon as the imposition is lifted. As of last night, the trade union further announced it would consider calling off the present action if even the government was prepared to agree to implementing pilot trials of the contract on a limited basis only with impact on patients and staff independently evaluated, but Hunt has not indicated any sign of receptivity to such a compromise. He remains undeterred.
Hunt has insisted that the contract imposition is necessary in order to deliver on a Tory party election manifesto promise of a seven-day NHS – the cynic might ask, “Since when was delivering on election promises ever a Tory priority?” – but, if creating a truly seven-day NHS was genuinely the motive, the government’s approach would be very different.
Whilst junior doctors already work on a seven-day basis (albeit with a reduced service in some non-emergency areas at weekends), Hunt is determined to stretch the present NHS resources for five days over seven days without an appropriate increase in spending on the service.
If the government wants the current workforce, which already provides a seven-day service for emergencies and in-patients, to cover all services, including elective, on a seven-day basis, it is not merely junior doctor numbers that will have to be increased.
Extra consultants, nurses, porters, receptionists, pharmacists, lab-staff, cleaners, radiographers, physiotherapists, ward clerks and so forth will also be required, but there is no evidence of government plans in the pipeline to increase the staff numbers to requisite levels.
The contract redefines Saturday work from 7am-5pm as ‘social hours’- with no pay increase, but offers a 30% premium for junior doctors who work more than one in four Saturdays. Hunt also announced he would lift basic pay from an 11% rise to a 13.5% rise. However, junior doctors called the rise a “cynical attempt” to “manipulate the figures”, claiming it would in fact amount to a real-terms pay cut of 26%, because of extra hours worked.
This stretching of resources inevitably means service provision and doctor morale will deteriorate; patients and their health will bear the brunt of these obviously-undesirable effects.
Junior doctors already experience “high levels of stress and anxiety” as a consequence of work in what Dr. Verity Sullivan has described as “low-morale conditions”. She wrote the following in the Guardian last July:
All doctors have had to spend a good chunk of their lives working weekend and night shifts. And while this antisocial pattern was “what we signed up for”, there’s no denying that such working patterns can be emotionally and physically tough, often to the detriment of family, friends and personal health. Studies have shown that working night shifts can increase your risk of serious health problems and that divorce rates are higher in those working in caring professions and with unpredictable working hours. And on a logistical note, transport and childcare costs can soar at the weekend, further adding to time and financial pressures. So if doctors are expected to work within these parameters for the extent of their career, we need to feel that we are being considered within this decision, not just being told what to do.
On top of this and as was acknowledged by the government’s own impact assessment of the proposed contract, the changes also expose female doctors to disproportionately discriminatory and unfair treatment. Accordingly, as well as being unsafe and unfair, the contract has been further described as sexist.
Junior doctor Tony Sorial has outlined that the “crux of the [present NHS crisis] is chronic underfunding” and points out that, whilst it might appear that raw or absolute spending by the government on the service is up (as the government are happy to claim), relative spending is down considerably. Sorial wrote:
Absolute spending increases make for excellent soundbite politics. In reality, the Government is enforcing real terms per-capita spending cuts, which does not make for a financially sustainable NHS. We currently spend less per patient on older, more complex patients. We continue to spend a smaller proportion of our GDP on healthcare than most of our counterparts including per-capita spending, well below the OECD median.
As a country we are living longer, have more complex healthcare needs and, as such, become more expensive to care for. In response to skyrocketing patient care and hospital overhead costs, we have allowed a systematic reduction in funding per patient.
The financial collapse of the NHS has one of two remedies, further privatisation or adequate funding through re-nationalisation.
It’s time for us, the public, the patients, to have an honest and frank debate about what the NHS is really worth and whether we are willing to put our money where our mouth is.
Basically, the NHS requires more staff, adequate compensation for its staff, consideration for the well-being of its staff and a sufficient budget to cover the needs and well-being of patients.
As junior contract negotiations have continued over the past number of months, Hunt, unwilling to budge on crucial terms and only offering a semblance of compromise in the form of an unsatisfactory or token eleventh-hour offer at the beginning of February (immediately before the second date of strike action), has repeatedly made public his intention to unilaterally impose the contract without the approval of those concerned in the event of the BMA refusing to comply with his wishes. Of course, the bargaining power of junior doctors is significantly weakened as their employer is a monopoly.
Throughout, Hunt described the prospect of imposing the contract as the “nuclear option”; rather militant terminology from himself, one might say. This was a threat, in other words; a threat to compel the BMA into submission. The BMA and junior doctors refused to buckle, however.
Consequently, Hunt finally declared after the second day of strike action that he would be proceeding with imposition after the BMA rejected his February offer.
Just under a fortnight ago, however, the Guardian reported that Hunt had apparently made a u-turn after he seemingly admitted he had no legal power to impose the contract as originally stated, after all. This apparent revelation coincided with the eve of the commencement of a legal challenge to imposition by five junior doctors in the high court.
The most galling thing about this was that Hunt appeared to have been using a threat – or a lie, essentially, if the Guardian‘s report was accurate – to try and dupe junior doctors into agreeing to an unsafe and unfair contract. That he has caused numerous strikes in the process of this possible intransigent charade is beyond reckless for a health secretary.
On the day following the publication of the Guardian story, Hunt dismissed the newspaper’s interpretation and clarified in the British parliament that it was indeed his intention to impose the contract, which he re-asserted he had the power to do. He articulated that his plan would go ahead as of August. It remains to be see how things, including the judicial review, will play out.
Whatever happens, this would not be the first time a deceit on the part of Hunt has been exposed during this long, drawn-out affair. In public pronouncements attempting to persuade the public to back his plans, he has repeatedly misrepresented “weekend” deaths figures from a British Medical Journal (BMJ) study in order to promote the notion that the changes he wishes to enforce are necessary to save lives.
The study, co-written by NHS England Medical Director Professor Sir Bruce Keogh, showed that around 11,000 more people die every year within 30 days of admission to hospital on Friday, Saturday, Sunday or Monday compared with other days of the week.
Even when taking into account the fact patients admitted on weekends tend to be sicker [because hospitals apply a higher severity-threshold for admission at the weekend], people were still 10% more likely to die if admitted on a Sunday compared with a Wednesday, the Press Association reported.
Researchers behind the study said a lack of consultant cover and “reduced” services could be contributing to higher death rates.
But they said it would be “rash and misleading” to conclude that an exact number of deaths could have been avoided.
In [a] letter, [the BMJ’s editor Dr. Fiona Godlee] said Hunt’s continued use of the 11,000 deaths figure despite this caveat “clearly implies that you believe these excess deaths are avoidable”.
She said: “I am writing to register my concern about the way in which you have publicly misrepresented an academic article published in The BMJ.
“Despite the authors’ very clear statements to this effect in the paper and elsewhere, you have repeatedly told MPs and the public via media interviews that these deaths are due to poor staffing at weekends, with a particular emphasis on medical staffing.
“This clearly implies that you believe these deaths to be avoidable. I ask you to publicly clarify the statements you have made in relation to this article to show that you fully understand the issues involved.”
Indeed, Hunt’s error in interpretation, sometimes quoted as “6,000 deaths” off the back of unverified and unpublished data, has been pointed out to him and his party on numerous occasions, yet, up until even yesterday, he was still insisting on pursuing this same dishonest line of persuasion. This would lead one to believe he is intentionally misleading the public, no doubt because he has no other cards to play.
When Hunt announced that he was moving beyond the threat-stage and finally resorting to imposing the contract unilaterally, he presented, to apparently bolster his position, a letter featuring the names and signatures of twenty chief executives of NHS trusts purportedly advising the government to “do whatever it deems necessary to end uncertainty”. In effect, Hunt was suggesting that these twenty chief executives all supported his imposition plans.
It soon transpired, however, that, whilst those chief executives supported the government’s offer to junior doctors, they did not agree with that offer being imposed. Subsequently, fourteen of the chief executives quoted disassociated themselves from the letter’s content. Is Hunt’s conduct the behaviour of a man that the public should trust ahead of their doctors, who actually do save lives and directly care for people’s health on a day-to-day basis?
After being granted a surprise meeting with Hunt whilst protesting against the imposition outside his departmental office last week, junior doctor Kumail Versi wrote of what was no more than a superficial interaction:
After talking to us for almost an hour, it was time for Hunt to attend his next meeting. We put forward our final points: would he continue with the imposition? Yes. Our hearts sank. We had thought we had made progress; we had hoped that the imposition could be lifted – that we could negotiate. No. The imposition remained in place. We were under no illusion with his continuing use of the word “imposition”, even following the confusion this week over whether the policy had been changed to mere “introduction”.
Once we left, I thought back over the meeting and I realised it had all been spin.
Hunt claimed that the reason for a seven-day NHS was not to extend elective care to weekends but rather to reduce the “higher weekend mortality rate”. But this just does not make sense. Professor Sir Bruce Keogh, the author of the report that Hunt keeps on quoting, insists that there is no evidence that increasing the number of junior doctors working will help tackle this issue. By repeating this claim publicly, there seem to be examples of patients not going to hospital on weekends, potentially, in some cases, leading to serious harm and even death. In fact, Hunt seemed to suggest it was actually senior doctors such as consultants who are the real cause of the weekend mortality rates but the contract for junior doctors is just the first step. Everyone else – watch out.
Clearly, Hunt arranged the “impromptu” meeting so as to enable him to present himself as being open to dialogue whilst having no intention whatsoever of actually changing his stance.
Junior doctor Rachel Clarke neatly summarised the roots of the exasperation and disappointment felt by her and her colleagues during an interview on BBC News in early February:
Many observers, stunned by Hunt’s gall throughout the saga, have been demanding that the prime minister David Cameron sacks his health minister on grounds of demonstrated incompetence. Hunt certainly has shown incompetence and gross negligence in overseeing what is now a total of five strikes.
However, those making such calls would be wise not to get their hopes up. The reality is that Hunt is a puppet; he is simply implementing Tory NHS policy. Hunt isn’t pulling any strings. If it wasn’t Hunt conducting himself in this dishonest and manipulative manner, the Tories would simply have another subordinate doing it in his place.
Hunt consistently asserts that he is just “doing the right thing”. This sounds wonderful, of course. How could anyone ever argue against someone who has no other motive in mind besides “doing the right thing”? Except, it would appear that Hunt does have other motives in mind.
In 2005, he co-authored a policy book advocating privatisation of the NHS. He has followed this book’s recommendations to the letter since becoming minister of health. The Tories simply cannot be trusted to safeguard the NHS for a myriad of reasons.
As Caroline Molloy outlined for Open Democracy last May, they are making huge, hidden cuts to hospital budgets, they have increased privatisation by 500 per cent (at measurable harm to patients), they have plans about how to make people pay for their NHS healthcare (besides through taxation), they have enthusiastically adopted the plan for a further £22 billion of closures whilst disguising it as an £8 billion “increase” and they have “some really sinister plans” to force patients to accept unproven treatments on pain of having their benefit cut.
This is “the right thing”, they say. I would suggest that what the Tories think is the right thing and what the population at large think is the right thing might differ rather significantly…
“Doing the right thing” is little more than a vacuous Tory slogan. It is “persuasive” and manipulative PR jargon that members of the party employ regularly now in order to attempt to rhetorically or morally justify potentially-unpopular policy. Of course, Hunt’s background is in PR.
In light of the above, it is hardly cynical to suggest that the little NHS badge Hunt permanently dons on his lapel might be a form of over-compensation or just simply a deceitful means of presenting to the public an illusion of support for the service. The Tories are out to dismantle the NHS and people should be wary of this.
If the narrative that Hunt is peddling was true – that junior doctors will experience a rise in pay, along with an improvement in working conditions, and that patient care will be enhanced – then what motive would junior doctors actually have to strike?
That’s the standard technique of privatization: defund, make sure things don’t work, people get angry, you hand it over to private capital.
Hunt’s inflexibility – what essentially amounts to rendering continued industrial action inevitable – is no doubt part an insidious strategy to turn public opinion against junior doctors and to deplete faith in the present NHS.
Fundamentally, the imposition of this contract will be irreparably damaging to the health service – a fact the Junior Doctors are acutely aware of.
By instigating chaos via an unfunded, unnecessary and unworkable policy, the Government will be able to claim that they’re out of options; that the only remedy left for a crippled NHS is to put it out of its misery and allow the private sector to step in – and with contracts worth around £25bn having been put out for tender in recent years with anything from 33 to 70 percent going to private companies, some worrying signs appear to already be there.
This is classic right-wing “shock therapy”: damage and destabilise a public service so much that you can present privatisation as the only way to revive it. The corporate vultures can move in to pick over the remaining flesh on the bones. Time and time again this strategy has been used around the world, not just on public assets but in some cases on whole countries – note Pinochet’s coup in Chile, mentored by laissez-faire economists like Milton Friedman.
If people wish to preserve the NHS, it is vital to maintain support for striking junior doctors over the coming days in spite of what will be an onslaught of government and establishment media misinformation. For if the junior doctors are beaten now, next in Hunt’s firing line will be the nurses. And then?…