The junior doctors’ contract dispute may seem on the surface to be a straightforward workplace dispute about
terms and conditions (1). I argue here that it is much more than that, that it is a key battlefront in the efforts to save
our NHS. If the battle to destroy/save the NHS can be likened to a chess match,
then the junior doctors’ contract dispute marks the beginning of the 'end game'. Its outcome will
determine the survival of our NHS.
KPMG’s head of global health predicted in 2010 that ‘in the future, the NHS will be a state insurance provider and not a state deliverer of healthcare’ and that the 'NHS would be shown no mercy' (2). If we are not careful, the battle to save the NHS as the dominant provider of universal healthcare is about to be lost. The three stages of this battle are/were as follows:
KPMG’s head of global health predicted in 2010 that ‘in the future, the NHS will be a state insurance provider and not a state deliverer of healthcare’ and that the 'NHS would be shown no mercy' (2). If we are not careful, the battle to save the NHS as the dominant provider of universal healthcare is about to be lost. The three stages of this battle are/were as follows:
The Opening
Game:
The creation of an
internal market within the NHS (2002) was an apparently benign opening gambit,
followed by a much needed but poorly thought out hospital building programme. The
public finance initiative (PFI) was worth £12 billion but turned out to be a hopelessly expensive
mortgage that would eventually cost the NHS £80 billion in repayments (3).
Once elected in 2010, the
present government began an expensive top down NHS reorganisation, dismantling
PCTs (Primary Care Trusts) while appearing to hand over power to GPs in the
form of CCGs (Clinical Commissioning Groups). This poisoned chalice would come
into play during the end game.
In 2012, the Health and
Social Care (HSC) Act removed the Secretary of State’s legal obligation to
provide healthcare for everyone and meant that the NHS became subject to EU
Competition law. This compelled
CCGs to
invite bids for ALL health services from ALL willing providers, leading to a
free market based system where expensive tendering processes would consume much
of the CCG budgets and time. The architect of this act, Andrew Lansley, now
works for Bain and Company to ‘improve its odds of gaining access to £5.8 billion of NHS work
that is commissioned to the private sector’ (4).
To add insult to injury, NHS funding almost froze after 2010
(rising by only 0.7% per year compared to the long term average of 3.7% per
year). ‘Efficiency targets’, a pseudonym for funding cuts, brought
NHS hospitals to their knees. Significant cuts in social care and district
nursing budgets as well as the privatisation of NHS 111 led to increasing
hospital activity and a critical shortage of hospital beds. As a percentage of
GDP, UK healthcare spending (8.5% of GDP) fell even further below the average
for OECD countries (below Slovenia and Finland) (5).
The Middle Game:
As predicted by many
(see my ‘election plea’), the flavour of the contest changed after the 2015 election
and the government chose to directly attack frontline staff. On 16 July 2015,
the Health Secretary Jeremy Hunt declared that ‘6000 people lose their lives
each year because we do not have a proper 7 day service in NHS hospitals’ and
that ‘by the end of this parliament, the majority of hospital doctors will be
on 7 day contracts’ (6). The implication was that hospital consultants were opting
out of weekend work (later proven to be a wildly exaggerated claim), being
overpaid if they did work weekends, and directly responsible for excess patient
deaths. He also accused doctors of lacking a sense of vocation and
professionalism. For reasons that are not clear, his attack then shifted onto
junior doctors (consultants should not assume that we are off the hook). In a ‘shock and awe’ approach, the government has also removed training
bursaries for student nurses.
Weekend mortality data
was distorted (7) to justify what the government described as a ‘7 day NHS’. No
mention was made of world class 24/7 emergency services that the NHS
already provides and it is still not clear what the government means/meant by a ‘7
day NHS’. Provision of elective (non-emergency) services over 7 days instead of
5 would require a 40% increase in resources (at an extra cost of £900 million),
yet the government insists on a ‘cost neutral’ approach that would stretch
existing 5 day resources over 7 days.
At the same time,
significant amounts of money were being spent on a number of chaotic, poorly
thought out vanity projects including the creation of a ‘paperless NHS’.
By this stage of the
contest, the ‘save the NHS’ camp was/is on the backfoot (Did I mention that the
line between middle and end game is blurred?).
The End
Game:
This stage of the
contest probably began a while ago but media attention has been poor if not
misleading, and most of us have been kept in the dark.
With CCGs struggling to
cope, CCG support services run by companies like KPMG, McKinsey and US health
insurer United Health will now carry out many of the ‘back office’ jobs (eg.
the design of future services), previously done by the NHS for the NHS (8).
Following the HSC Act
2012, 40% of CCG contracts (worth £3.54 billion) have been awarded to private
healthcare companies (compared to 41% awarded to the NHS) (9). This figure is set
to increase to £20 billion over the next few years. Note at this point that
private healthcare must cherry pick profit making services (for example,
elective hip replacements rather than emergency trauma surgery; they have a
legal obligation to their shareholders to do so) while the NHS is left to
provide less profitable services.
When TTIP (an EU US
trade deal) goes ahead at the end of the year, many of the above changes may
become irreversible (according to Michael Bowsher QC, a former chair of the Bar
Council’s EU law committee) (10). US healthcare companies have already begun to
invest heavily in UK facilities (11).
To make things worse, the
PFI burden is only just about to kick in for many NHS trusts. Annual PFI
repayments will peak at £2.7bn in 2029/30.
According to Professor Keith McNeil, former CEO of Addenbrooke’s
Hospital, the ‘only thing holding NHS together now is the dedication, passion,
commitment of frontline workers’. This is precisely why the junior doctors’ contract
is such an important battlefront and why we should resist attempts to break
the backbone of acute and elective NHS care. If the government imposes the current
contract, recruitment and retention of high quality junior doctors to provide
24/7 care will become even more of a challenge. It doesn't take a rocket scientist to work out that patient safety will be
compromised by this contract.
In many ways, shifting the attack from consultants to junior doctors after
July 2015 was an error of judgement by government in this fight, a single
mistake in what has otherwise been a powerful ‘shock and awe’ onslaught. The
government underestimated the courage and political will of 54,000 junior
doctors, and the conflict has highlighted the looming threat to the entire NHS.
Anyone who says that
the junior doctors’ contract dispute has nothing to do with saving the NHS is
at best missing the whole picture, at worst cheering for the wrong team. In the ongoing battle
to save the NHS, we should all be supporting junior doctors and at the very least hope for a draw. A check mate would be a huge but unlikely bonus.
Vinod Achan is a Consultant Cardiologist at a well known NHS Foundation Trust
