JUNIOR DOCTORS DISPUTE IS A FIGHT FOR THE NHS

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:

 

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

AS A CONSULTANT, I WILL SUPPORT MY JUNIORS IF THEY STRIKE

Junior doctors are deciding on whether to strike for three days. This is the final attempt to kickstart fair negotiations between the BMA and NHS Employers over a new junior doctor’s contract. Although we would all prefer that a strike did not happen, I will be supporting my juniors for the following reasons:

1.     Junior doctors form a vital part of the NHS. They are a dedicated, hardworking and vital part of the NHS family and MUST MUST be valued and respected. They also happen to be the hospital consultants and GPs of tomorrow. Changes to their contract are being imposed on them with a refusal by NHS Employers to negotiate on vital points. Proper negotiations with NO pre-conditions must start immediately. Let's not forget that Jeremy Hunt has also threatened to impose new working arrangements on consultants.

2.     We must attract the best students to medicine and the best doctors to frontline medicine. Recent data shows that Britain needs 26,500 more doctors to match the OECD average. The NHS is already the most cost effective universal healthcare system in the world and existing resources are being stretched to breaking point. The new contract is one step too far. A flow of junior doctors away from the UK or frontline medicine has already begun. Let’s not make that problem worse.

3.     The new contract imposes a new definition of ‘normal working hours’ on junior doctors, and penalises those working in specialities with a greater ‘out of hours’ commitment (such as emergency medicine, cardiology, paediatrics etc). This sort of work needs to be recognised and paid appropriately. Removing safeguards that prevent doctors from working even harder exposes them to abuse and may harm patients. Women in medicine must not be penalised for taking maternity leave. We should be working harder to help all doctors achieve a good work life balance.

4.     Clinical scientists are vital to good healthcare research. The new contract penalises junior doctors doing clinical research.

5.     The NHS already delivers 7 day urgent care. So when Jeremy Hunt, David Cameron and the media say that these contract changes are necessary to turn the NHS into a 7 day service, nobody really understands what they are saying. Can we assume that they are talking about elective or non-urgent care? If the government wants to create a 7 day non-urgent service, a 30% increase in resources and funding (and not just doctors) may be required and we all know that that won’t happen. Imposing contract changes on junior doctors, then consultants, GPs, nurses and everyone else in the NHS is not the answer.

6.     The assumption that ‘excess weekend deaths’ are avoidable by making doctors work harder and longer is rash and misleading. Even the authors of the cited papers make this clear. Patients admitted on the weekends were more sick, almost twice as likely to be an emergency admission (than on a weekday), were at NO extra risk of dying during their hospital stay and had a small increase in mortality 30 days after admission (as would be expected). So when politicians and the media say that a ‘7 day NHS’ made possible by changes to doctors’ contracts will ‘save 6000 lives’, they are not being truthful. At best they don’t understand the data, at worst they are deliberately misleading the public.

7.     We have had enough of political spin. Talk of militant doctors, danger money, doctors being misled by the BMA, doctors lacking a sense of vocation and worse is starting to make negotiations with the present government impossible.

8.     This is only one of many spanners. Disruption of the NHS by refusing to negotiate fairly with junior doctors is just one of many spanners being thrown at the wheel of the NHS. See my pre-election blogs for a summary of how the Health and Social Care Act of 2012 and now TTIP will conspire to break the NHS. We only have to look at Jeremy Hunt’s predecessor to see where this might be going.

Vinod Achan

Vinod Achan is a Consultant Cardiologist at Frimley Park Hospital, Surrey

 

AN ELECTION PLEA FOR THE NHS

On 9 June 2011, I attended a medical networking event at the Oxford and Cambridge Club in London. At the end, a man with an American accent stood up and spoke about how backward our NHS was, and about how everything was about to change as we adopted a ‘modern’ US style healthcare system.

Having worked in the US and experienced first-hand the striking contrast between both systems, I stood up and responded. The NHS is an excellent model for cost-effective universal healthcare, promising equal access to high quality healthcare without fear of bankruptcy when patients are at their most vulnerable. The US, despite all its innovation and technology in various cathedrals of excellence, spends far more on healthcare with worse outcomes and denies healthcare to its weakest.

Less than four years later, that vision of a US style healthcare system is being realised in the UK at a faster pace than many of us imagined possible.  The NHS has been reorganised and is now on its knees with flat-line funding since 2010, morale at an all-time low and more threatened ‘efficiency’ cuts. The Health and Social Care Act passed in 2012 set this government’s agenda for disruption of the NHS. It had two main effects.

A. Control of the NHS budget was handed to GP-led Clinical Commissioning Groups (CCGs) that were doomed to fail without adequate support. CCG support services have sprung to their aid, so that many jobs previously done by the NHS for the NHS (eg. the design of future services) will now be carried out by companies like KPMG, McKinsey and US health insurer United Health (1). Note that in 2010, KPMG’s head of global health believed that ‘in the future, the NHS will be a state insurance provider and not a state deliverer of healthcare’ (2).

 

B. CCGs are also being forced to open up every part of the local health service to private companies. Time-consuming tendering processes in which the NHS is no longer the preferred provider will lead to expensive bidding contests. In the US, administrative costs account for 20% of healthcare costs compared to 7% in the UK (prior to the 2012 Act). Private organisations will cherry-pick profitable services, leaving NHS providers to mop up less profitable work.

In order to save the NHS, the Health and Social Care Act 2012 must be revoked. The NHS must become the preferred provider of healthcare services to protect it from competition. We must resist changes that will make the NHS even more expensive and unaffordable. Electoral promises to pour £8 billion into the NHS mean nothing if the money flows out of the NHS and into private hands. 

Add to this equation the impending TTIP (Transatlantic Trade and Investment Partnership) between the US and EU which would make it impossible to reverse these changes, and the future of the NHS starts to look very bleak. Cameron has described fears that TTIP might damage the NHS as ‘bogus nonsense’ (3).

If like me you regard the NHS as a national treasure to be defended from global corporate interests, and if you agree that all of us (and especially the most vulnerable amongst us) should have access to healthcare free at the point of delivery without fear of bankruptcy, then please consider all of the above when casting your vote tomorrow.

Vinod Achan

This blog had had 910 views by day 4.

To see my 'Elevator Pitch' on NHS reforms in 2013, see here.

ABPI Sponsorship of NHS Debate: What's the Catch?

I am looking forward to the #GuardianLive debate tonight where the three main political parties will discuss the future of the NHS. Guardian’s health correspondent Denis Campbell will chair, and guest speakers will include Norman Lamb MP, Minister of state for care and support, and Liz Kendall MP, Shadow minister for care and older people. Should we be surprised that such an important debate is being sponsored by the Association of the British Pharmaceutical Industry (ABPI)?

The relationship between healthcare and industry (both pharmaceutical and medical devices) has always been an important but difficult one. Mass production of Penicillin during World War Two would not have been possible without the hand of industry. Lifesaving medication like Aspirin and Beta blockers have been developed and produced by industry. Similarly, none of the devices that cardiologists implant routinely, coronary stents and pacemakers for example, could have been developed without close collaboration between industry and clinicians.

Yet relations between healthcare and industry are at a low point. Many conflicts of interest arise when pharma influences healthcare delivery. The NHS drug budget is approximately £10 bn per year and rising. Looking at just the top 10 prescribed drug classes by cost, more than £3bn was spent in England alone on branded drugs where in most cases equally effective cheaper generic alternatives are available. Overdiagnosis (by changing diagnostic criteria or incentivising doctors to diagnose), lowering the threshold for treatment (as with statins, for example), and limited evidence that ‘innovative’, more expensive treatments work, all favour industry’s agenda. Many of these damage the NHS which strives for universal delivery of cost effective and evidence based treatments. The National Institute for Health and Care Excellence (NICE) has been set up to strike a balance, ensuring that effective and affordable treatments are available to everyone. How the different political parties will overhaul NICE following the election is of huge interest to all (see this excellent Guardian article, sponsored by ABPI).

Data transparency in clinical trials carried out by industry is an important issue. It has been estimated that only half of all registered and completed clinical trials are published. Positive trials are twice as likely to be published than negative ones. One example of this is the failure of the pharmaceutical company Roche to disclose all trial data concerning Tamiflu to the Cochrane Collaboration. The UK government has spent £500 million stockpiling Tamiflu on the basis of data that is not complete. Patients giving their consent for use of their personal data in these trials are seldom made aware of this. Studies suggest that only a fifth of all new drugs brought to market offer any advantage over existing therapies.

Key themes for tonight’s debate include:

·        If the NHS has finite resources, how should they be spent? Is it more cost effective to outsource services?

·        How can we improve access to innovative, new drugs to improve patient care?

·        Patient data: who should have access, and why?

It is easy to see how the ABPI view on these may differ from that of most NHS clinicians. The relationship between clinicians and industry is an essential one. But there are serious tensions as well. I hope the debate tonight reflects these.

Vinod Achan

Michael Sheen speaks in support of the NHS

Actor Michael Sheen gave one of his finest performances yet in support of the NHS this weekend. He spoke in Tredegar, Wales, birthplace of Aneurin Bevan, architect of the NHS. Sheen’s speech, delivered with impressive force, should be an inspiration to all those defending the NHS. Here are some key extracts:

·       In 1945, Aneurin Bevan said, “We have been the dreamers. We have been the sufferers. And now we are the builders”. And my god how they built and what they built. Every bit as much a wonder of the world as any architectural marvel or any natural miracle. The National Health Service. A truly monumental vision. The result of true representation, of real advocacy. A symbol of equality, of fairness and of compassion. The nation that swept the post-war government into power was made up of a people that had faced the horrors and hardships of the Second World War. And bound together as one community, they had been sustained and inspired by a feeling of comradeship, and sense of responsibility for their fellow man and woman. Compelled to help those in need and those in hardship.

·       In his book ‘In Place of Fear’, Bevan said, “The collective principle asserts that no society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means”.

·       We do not turn our backs on those facing hard times. We do not abandon them or exploit their weakness. Because they are us. If not now, then at some point and inevitably, they are us. We are not afraid to acknowledge that we can be ailing. That we can find ourselves weak. We do not shy away from that hard truth. We embrace it because in that way, we are always strong. We leave no-one behind. We only say we cross the finish line when the last of us does. Because no-one is alone. And because there is such a thing as society.

·       It’s no surprise that people feel disengaged with politics. Never an excuse not to speak up for what you think is right. You must stand up for what you believe. But first of all believe in something. Because there are plenty out there who believe in grabbing as much as they can. They won’t say it. They are too smart for that. No one says they want to get rid of the NHS. Everyone praises it. It’s as powerful a symbol for goodness that anyone has.

·       This is beyond party politics. This is about who we want to be as a nation. Too many people have given too much and fought too hard, for us to give away what they achieved and be left with so very little.

 

For a full video of the speech see here:

 

For more on Aneurin Bevan, see here.

Vinod Achan

THE ‘HOSPITAL AS A BATHTUB’ MODEL HELPS EXPLAIN THE A & E 'CRISIS'

 

A surge in hospital activity over winter months is predictable, yet this winter we face unprecedented challenges at the frontline. There is much talk of an A and E (Accident and Emergency) ‘crisis’ but A and E represents only one of several interfaces within the healthcare structure.  Consider the following simplistic bathtub model of hospital flow to look at how primary care, secondary care and social care interface with each other.

1. The hospital is a bathtub. If the size of the bathtub reflects the number of hospital beds, we have in the UK the smallest bathtubs in Europe (half as many beds per head of population compared to France; see here to compare).

 

2. The water level in the bath is determined by patient flow into the hospital (via the tap) and out of the hospital (via the outlet pipe). The tap in turn is determined by a number of factors including the following: access to primary care, telephone advice (NHS 111), and patient choice (to attend the ED rather than see a GP).

3. Flow out of the hospital on the other hand depends on patient recovery, access to rehabilitation beds and social care.

4. There is an additional re-entry circuit: when flow through the backdoor is obstructed and social care is unable to cope, outflow is diverted back to inflow (the hospital readmission).

 

Recent changes to the NHS have had an impact on this model at both ends. 

Recent changes mean that the tap has been turned to full. The number of district nurses, who play a crucial part in keeping people out of hospital, has fallen by 40% over the last decade. General practice, the jewel in the crown of the NHS, is also vital to keeping people out of hospital but now being stretched to breaking point. Recent changes following the Health and Social Care Act 2012 have distracted GPs from their clinical work and led to older GPs seeking early retirement.  Patients are finding it harder to access primary care and opt instead for the emergency department (ED).  NHS 111 is sending larger numbers of patients to the ED (see below).

 

At the same time, the flow of water out of the bath is being blocked. Social care cuts have made it harder to get patients home.  Many smaller cottage hospitals, rehabilitation facilities, and nursing homes have been closed.

 

At the easiest of times, hospitals are run at 100% capacity for maximum efficiency. But open the taps to full by overwhelming primary care, then plug the outlet pipes by cutting social care and rehabilitation beds, and the bathtubs of the NHS, no matter how efficient, will overflow when winter arrives.

 

Vinod Achan

Vinod Achan is a Consultant Cardiologist and Consultant Lead for Emergency Angioplasty at Frimley Park Hospital (now part of the Frimley Health NHS Foundation Trust)

 

Why Do Doctors 'Fail'? A British Perspective

Atul Gawande's first 2014 Reith Lecture is eagerly anticipated by many including myself. He is an excellent surgeon and author, as well as an eloquent speaker, and his views on why doctors fail are of enormous interest to all of us. Nevertheless I can't help but feel that a British answer to the same question might be rather different to his. 

 

In a short preview on the BBC Radio 4 website, he explains that there are three reasons why doctors fail. 1. Ignorance. 2. Ineptitude, the failure to apply our vast knowledge of disease and its treatment effectively. 3. Hubris, the failure of doctors to realise their limitations.

 

I have no idea what course his talk will take tomorrow (I will have the radio on at 9AM) but I hope he will take into account the following point.

 

In most societies, doctors 'fail' to deliver the best possible care to all their patients due to a lack of resources, constraints placed upon them by systems they work in, and political factors. In the US, resources are concentrated on the few who can afford excellent healthcare while a large percentage of uninsured are 'failed' by their healthcare system, government, and possibly doctors. In the UK we choose to distribute those limited resources more fairly, so that access to healthcare is universal and not determined by privilege.

 

Where we 'fail' to consistently deliver the best possible care to every single patient due to limited resources (and the data suggests the NHS is a doing an excellent job compared to other healthcare systems in the world), please do not mistake this for ineptitude.

The real challenge for doctors in the future will be how we deliver existing treatments to everyone in the world cost effectively. This is in fact an area in which the UK leads the world. A shining example of this is the way the NHS delivers 24/7 heart attack care to everyone at no cost to the patient (see here). A system which cannot allow this to happen is the real failure in medicine. 

 

 

Disclaimer: Dr Gawande was an undergraduate at Stanford and then a Rhodes Scholar at Oxford. I was an undergraduate at Oxford and then a Fulbright Scholar at Stanford. Dr Gawande was named by Time magazine as one of the world's most influential thinkers. I was not.