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A Tale of Two Thickies

Posted by Dr No on 11 February 2016

two_thickies.jpgOf all the reasons to end a long and bitter industrial dispute, imposing an unwelcome contract on a demoralised workforce to "end the uncertainty" has to be the most bizarre, given the inevitable outcome of the imposition will be not less, but more uncertainty. The demoralised workforce, our junior doctors, are already in bad shape, overstretched and in poor morale. Record numbers are considering – though we don’t yet know how many will pull the ejector seat lever – working abroad. Late last year we learnt that almost half of juniors completing their foundation training chose not to proceed directly with their training – a sure sign of ambivalence about the direction of their chosen career. Hospitals face unprecedented recruitment problems, winter pressures are now being mirrored by summer pressures, with the imminent prospect of all year round pressures. The health service is in a critical way, at risk of implosion. So what does the Health Secretary do when he doesn’t get his own way with the juniors? He hits them on the head. Hard.

The junior doctor bear now has a sore head. Many in the media, including notably the usual BBC goons, frame the dispute as one over marginal pay and conditions. Hugh Squimm, the BBC health editor, who seems almost so hygienic as to be unhygienic, inclines to present the story as if he were reeling off results from the local flower show, with a cheerio-for-now manner better suited to benign weather forecasts. But this dispute isn’t about the banalities of marginal pay on Saturday afternoons. It’s about something, or rather two things, that run much deeper. The first is safety, and the second is morale, or more precisely, though Dr No doesn’t normally warm to the modern street use of the word, respect. The two are heavily connected. However hard individual members try, a thinned out, demoralised workforce that feels it lacks due respect is always going to struggle to provide as safe a service as one that is well staffed, and content in its daily round.

The government line is that it has a manifesto commitment to deliver a seven day NHS, and that the new contract will go some of the way (consultants and other hospital staff will be next in line) towards facilitating this, by making it easier for hospital managers to roster juniors to work over weekends. Never mind that juniors already do work at weekends, or that the questions about admission day of the week mortality are far from answered. It’s a simple common Tory plug, no doubt aimed at hard working patients, who also have to work weekend hours. Add in beefed up basic pay for juniors – only today the government ‘discovered’ an extra two and a half percent on top of the existing eleven percent increase – and further optimistic, though in reality likely to be more notional, limits and safeguards on over-working, and, well, what could be fairer than that?

But consider this. The new contract is set to be neutral on the overall bill for junior doctors’ pay. There are no plans to recruit, at considerable expense, large numbers of new junior doctors; indeed, all the indications are that a combination of factors, now aggravated by the contract imposition, are causing attrition in junior ranks. This means that the reality of a seven day NHS is that the juniors who currently provide a seven day emergency/five day elective service are going to be spread thinner, to provide a seven day emergency and elective service. The already thin over-stretched gossamer of junior doctor cover is to be spread even thinner. It is only a matter of time before splits appear, and patients start to fall through the cracks.

It is here that the BMA, rarely the sharpest scalpel in the dissecting room cabinet, missed a big trick. Instead of allowing the dispute to be portrayed as one of pay and conditions, with the inevitable consequence that opportunistic opponents would cry ‘greed’ and ‘self-interest’, the doctors’ leaders should have focused much harder on the real threat to patient safety inherent in spreading too few doctors over too many days.

If the BMA was thick, then so too it seems has been the government. Though the conspiracy theorists have it that the Tories are cynically and deliberately compromising the day to day safety of the NHS, as a prelude to calling in the private sector cavalry – and in this respect there is that rather awkward 2005 pamphlet co-authored by the current Health Secretary, along with other notorious Tory coves, that called for the denationalisation of the health service – it seems more likely to Dr No that the junior contract imposition announced today ‘to end uncertainty’ is more of a bull-headed cock-up than part of a running conspiracy. The Health Secretary, who spends too much time talking as if he were trying to explain how school meals work to a slow-witted child, appears simply not get that imposing a unwelcome contract on a stretched demoralised workforce is a recipe for disaster. A tale of two thickies then, but without the best of times, only the worst, to come.


Generally agree with your sentiments, however, I am more minded to consider this as a conspiracy and not a cock-up.

Is Jeremy Hunt a knave or a fool? I am inclined to think he is a knave.

Dr No thinks he is most likely a knave and a fool. It is a core Tory belief that national and thus in their view monopoly health service provision (never mind reality) is a Bad Thing and must therefore be dismantled. The railways are the model and example. The two momentous changes to the NHS in the last 30 years, the purchaser provider split and the more recent Health and Social Care Act (removal of the SoS's duty to provide) are clear evidence of the Tories' direction of travel. The 2005 pamphlet, co-authored by Hunt, goes much further than denationalising the provider side, calling as it does for a move to an insurance based purchaser side. In the absence of a clear distancing statement by Hunt, there is no reason not to assume that today he holds largely the same views that he did in 2005.

He is a fool because he forgets the power of doctors. At the inception of the NHS, the then politicians realised the only way to have their way was to bribe doctors (either with cash or the independent contractor status) and while that doesn't put our dearly beloved profession in the best of lights, it does show a degree of real-politik absent from today's politicians.

Hunt's cowardly 'I'm only imposing it because that's what the trust chiefs asked me to do' gives us further insight into the man's lack of moral fibre. Interestingly ten or more trust chiefs have already gone public saying that, while they approve of the contract, they do not approve of its imposition.

Perhaps the greatest danger here is that instead of being a hot war, the dispute will become a cold war of attrition. The BMA, already well known for its inability to organise a piss-up at a wine club, will continue its amoeba style leadership. Among the rank and file, Dr No though not a betting man wouldn't mind betting that this morning there are more than a few junior doctors across England wondering about wider career options. Adapting the old saw you pay peanuts, you get monkeys, if you treat people like monkeys, then down the road you may find all you have to show for it is a handful of empty peanut husks, with the monkeys nowhere to be seen. We should all be very concerned.

Oh, and by the way, Welcome Back JD!

From me re ALL of the above and according to the more sensible papers, most of the public support our junior doctors and do realise they have a very tough, demanding job.
NO-ONE enters a hospital career for cash - no way ! I am sorry to say I do think this is slooooowww privatisation by the back door.
The Contract will dispel some and gradually a more private service will not actually need all these doctors & nurses - not at current levels anyway.
Feel free to disagree people but how do Insurance companies make profit ? Less staff / more premiums.
If Hunt was REALLY serious about NHS Reform - he would re-organise, improve levels of care, THEN talk pay.

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