Monthly Archives: September 2015

Half of all services now failing as UK care sector crisis deepens – the failing safety net

Daniel Boffey in The Guardian 26th September reports: Half of all services now failing as UK care sector crisis deepens – Five years of funding cuts blamed for crisis threatening the welfare of elderly and disabled people

It is not only going to get worse – it is getting worse as you read.. Don’t get old in the UK…? The crisis is the responsibility of ALL political parties… ,the fear they have installed into professionals speaking out, and the media for not grasping the nettle and initiating informed debate. If you have not planned (and saved) for the failing safety net you may well be in trouble..

Nearly half of social care services visited by inspectors in the past year were found to be failing the frail and vulnerable, in what relatives and experts say is a symptom of the growing financial crisis in the sector.

An update given to the board of the Care Quality Commission last week showed that 41% of community-based adult social care services, hospice services and residential social care services inspected since last October were inadequate or required improvement. Of the 8,170 services examined, less than 1% (38) were outstanding and 58% (4,381) were good, according to the chief executive’s report, which was delivered last Wednesday.

The CQC’s chief inspector of adult social care, Andrea Sutcliffe, told the Observer that the figures were extremely worrying. They will raise fresh concerns about the state of the sector after social care providers and council leaders warned in a joint submission to the Treasury last week that the fragility of the care sector was affecting their ability to perform their legal duties to elderly and disabled people.

Earlier this year, this newspaper revealed that the CQC was receiving more than 150 allegations of abuse of the frail and elderly in social care settings every day, prompting Sutcliffe to warn that a broken system was turning good people into bad carers as a consequence of poor working conditions, a lack of training and inadequate staffing.

There is also growing evidence of the crisis having an effect on the health system. A key part of the reason why Addenbrooke’s hospital in Cambridge, one of the NHS’s most prestigious hospitals, was put into special measures last week was…..

…Colin Angel, policy and campaigns director at the UK Home Care Association, which represents providers of services to people in their own homes, said it appeared that the most severe drop in standards was in nursing homes, where it was increasingly difficult to hire appropriately trained staff. “While CQC’s new ratings show the home-care sector delivering significantly better results than residential nursing care, it is difficult to imagine how adult social care as a whole can achieve marked improvements during a financial crisis,” said Angel.

“Recruiting experienced nurses for residential care is increasingly challenging, and the turnover of home-care workers is unacceptably high due to the terms and conditions available, particularly given employers’ fears over bearing the yet unfunded costs of the forthcoming national living wage.”
Sutcliffe concluded: “I am glad that the majority of the adult social care services we have rated so far are proving to provide safe, high-quality, effective and compassionate care. However, that 34% of services rated to date require improvement and 7% are inadequate is extremely worrying because of the detrimental impact these deficiencies can have on the health and wellbeing of people using services.

“We have been prioritising our inspections according to risks and concerns, so our findings may show a higher proportion of poor care at this stage than when all 25,000 services have been inspected at least once by next September.

“Nevertheless, it is unacceptable for people to be let down by services that are meant to give them the care and support they need, and we are committed to tackling poor care when we find it. We will continue to be a strong regulator, setting clear expectations for providers to improve and by taking action to force that improvement, if necessary.

“However, all parts of the adult social care system need to play their part to make sure people can receive the high standard of care that they deserve and that we expect. That includes providers taking their obligations to the people they serve seriously and supporting their staff, as well as commissioners and funders providing the appropriate resources for them to do so.”

Another one bites the dust:  reports in the Guardian 25th September 2015 – East Sussex NHS trust in special measures after CQC inspection – Care at the trust was rated as good, but overall it was inadequate, with concerns over maternity and outpatient services and Richard Vize reports on the same day: Addenbrooke’s: why are internationally renowned hospitals struggling? – A number of specialist hospitals are facing serious problems with their district general services

Disconnected from reality the politics of health is in “sound bites”. Universities have perverse incentives to appoint students from overseas. Who will be the first party to address health honestly?

When Mr Hunt promised to have GPs work weekend he did not anticipate that their would not be the demand. GPs have been deskilled in emergency care, and in seeing patients without their notes, so they avoid weekend and evenings with cooperatives if they can afford it. Disconnected from reality the politics of health is in “sound bites”. Universities have perverse incentives to appoint students from overseas. Female doctors excel in General Practice but they are over-represented in the Hospital posts…. Prof Meirion Thomas’ Opinion is interesting… Who will be the first party to address health honestly?

Sophie Borland in The Mail 29th September reports: Patients shun out-of-hours GP surgeries: Half of sites in flagship scheme cut appointments back because of a lack of demand

The inability to plan longer term is evident in the Express headline (Jon Bachelor 29th September) : Junior Doctors descend on Westminster in protest at ‘unsafe’ working contracts – HUNDREDS of trainee medics gathered in Westminster this evening to demand the Government halt controversial changes being imposed on Junior Doctors’ contracts and Scott Cambell on 23rd September in the same paper: British students BANNED from doing medicine at uni – as NHS forced to hire foreign staff – ONLY foreigners will be allowed to study a certain degree course on medicine at a British university, it has emerged – amid a staffing crisis in NHS hospitals.

Marie-Louise Connolly for BBC News 16th September in N Ireland reports: Northern Ireland GPs say urgent action needed over ‘crisis – The Royal College of GPs (RCGP) says 400 more doctors are needed by 2020 and they must be allowed more time to see patients.

Nick Aresti in The Huffington Post politics blog on 25th September comments on “The Smokescreen of the Junior Doctor Contracts”

British healthcare workers discovered DNA. They designed the first antibiotic. They invented the ophthalmoscope, the thermometer, the CT scanner and the MRI machine. They were the first to stop and start a beating heart and the first to conceive a baby in a test tube. They operated on me within weeks of being born, and recently gave my elderly relative first class health care when she broke her hip.

I am proud to work for the NHS. It’s a wonderful institution that we should all be proud of. I remember I once asked a consultant why he went over and above what was expected of him, in effect doing the job of two consultants. Without a moment’s hesitation, he replied; “the NHS took care of me so well in my training, that I owe it to the NHS”. Echoing his sentiment, other than the well being of my patients, what underpins my dedication to the NHS is that the NHS has looked after me, and so I must look after it. Many of my colleagues have resisted offers to double their salaries in consultancy firms and plenty have refused offers of working abroad, for better working conditions, hours and pay.

I will attempt to explain the injustice surrounding the proposed contracts. You have heard the rhetoric. You have seen the petitions across social media. You have seen the facts and figures demonstrating a 30% cut in the salaries and changes in the working patterns of junior doctors, most of whom in my experience work tirelessly for their patients. If you were faced with a cut in your salary by a third, when you had only ever exceeded your targets, you would probably be left with a distinct feeling of injustice. You would probably consider seeking alternative employment.

What you may not realise, is that the contract changes go further than a simple pay cut. Female doctors will struggle to take maternity leave due to the contract structure, and even the choice of when to take annual leave will become more rigid than optional. The next Francis Crick (co-discovered the structure of DNA) or even Bruce Keogh (National Medical Director) will be denied the necessary support to pursue research degrees and perhaps the expertise it takes to run the only health service in the world that is free at the point of service.

What I find particularly insulting regarding the proposed new contracts is not the pay cut and changes in working patterns, but the government’s smoke screen of patient safety as an excuse to push through the changes. In my opinion, the disharmony amongst the medical profession caused by the threat of the new contracts has caused a far greater risk to patient care than the current working patterns. We all know what the new contracts are about. Money.

For now, our rotas will remain covered. Our patients will still be seen, and the most vulnerable given first class medical treatment. But how long will this last? Junior doctors will begin to leave in droves. Already 40-60% of foundation doctors are choosing not to apply for specialist training. A third of GP training posts are unfilled. So are half of A&E training jobs. We have seen a dramatic rise in the number of applications for ‘certificates of good standing’ – the paperwork required to work abroad. Those who have gone to Australia, New Zealand and North America, are deciding not to come back. We are already facing a recruitment crisis that could alarmingly escalate. The future gaps in workforce will be the greatest risk to patient safety, not the current contracts, as the government is suggesting.

Overwhelming evidence shows that a valued, supported and motivated workforce leads to better health care and productivity (Sears Employee-Customer-Profit chain). Demoralising the junior doctor workforce will be the next great risk to patient safety.

This contract change is not only unjustified, but also plain and simply wrong. Goodwill is the oil that lubricates the NHS machine, and junior doctors its fuel. Both are at risk of quickly becoming in short supply.

Nick Aresti is a junior doctor working in London.

Food for thought from Professor J Meirion Thomas on 2nd Jan 2014 in Mailonline: Why having so many women doctors is hurting the NHS: A provocative but powerful argument from a leading surgeon

 

 

Stop the NHS runaway train before it’s too late. The health service is consuming all our wealth ..

Ross Clark in The Times 29th September 2015 tells it as it is. Stop the NHS runaway train before it’s too late. The health service is consuming all our wealth ..  Unless the professionals (Nurses and Doctors) buy into the ideology it can only get worse….Most of us hear lies when we hear politicians talking about the health services.. Overt rationing now will be less painful than covert rationing continuing as infinitum..

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The NHS has expanded so quickly over the past 18 years — from consuming 5.3 per cent of GDP to 8.2 per cent — that by my back-of-the-envelope calculation it will finally consume the entire UK economy about the year 2100. Maybe it will be sooner. A new threat to NHS financial stability has emerged: thanks to the increasing complexity of drugs it will cost a lot more in future to produce generic versions.

At present, drugs typically fall in price by 95 per cent once their patents expire. But new drugs that rely on biological agents are expected to fall in price by only 25 per cent, drastically cutting the £13.5 billion the NHS saves every year by using generic drugs.

The NHS should have cottoned on much faster to the fact that generic drugs cannot be relied on indefinitely. It should be using its power in the marketplace much more to push prices down. Pharmaceutical sales reps should be quivering in fear that the NHS’s central buyers might pass over their products.

But the bigger problem lies in the consulting room. Is it really necessary, as revealed in Health Survey England 2013, for the NHS to be prescribing 18.7 medicines for every man, woman and child in the country? Given that I didn’t have a single prescription last year, and I suspect there are many, many others like me, there must be a fair slice of the population which is popping back the pills on an Elvis Presley scale.

We know about the chronic over-prescription of antibiotics because it has caused serious problems in bacterial resistance. If they are still being over-prescribed when doctors have been warned endlessly about the problem, then how much more extensive must be the over-prescription of socially more benign drugs?

Prescribing drugs is far too built in to the culture of the NHS. It has become a way of keeping GPs’ consultations short and to the point. It is as if doctors are saying: “Look, how about I write this for you and then you go away and I can get on with the next patient?”

It isn’t just the price of drugs that we are going to have to contend with if we are going to contain the NHS’s ever-expanding budget. We are going to have to ask ourselves: how did we get to a situation where 50 per cent of women and 43 per cent of men are on regular prescriptions — and how much of these are really necessary?

Patients will suffer ‘with or without a strike’

Letters in The Times 29th September give an accurate assessment. If politicians and bureaucrats wish to control the profession they need a long term strategy to produce overcapacity:

Patients will suffer ‘with or without a strike’

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Junior doctors are brewing up for strike action over the government’s imposed contract, but no one will be the winner

Sir, The new junior doctor contract will remove vital protections on safe working patterns and see a return to us working up to 90 hours a week. With the best will in the world, we cannot be held responsible if such dangerously long hours put patients directly at risk.

The new contract will also lead to an exodus of highly trained NHS professionals to countries or jobs where they will be better respected and rewarded. Over the past decade, our job conditions have been eroded by pay freezes, banding reductions, pension cuts and the removal of free hospital accommodation. If the government imposes this contract, junior doctors (who have a basic starting salary of £23,000) will face a pay cut of about 30 per cent — leaving those who have graduated with well over £50,000 of student debt and earning less than the national average. None of us go into the profession for the money but rather out of an innate desire to help to save and improve lives. Yet a line has now been crossed that breaches both safety and fairness.

We are all junior doctors and members of the National Health Action Party, and urge the health secretary to withdraw this ill-judged contract and thereby prevent what is likely to be a vote in favour of a strike — for which he will bear ultimate responsibility.

Alex Ashman; Dr Hugh Cummin; Dr Georgina Fozard; Dr Jamie Keough; Dr Julian Ormerod; Dr Benjamin Post; Dr Piyush Pushkar; Dr Poppy Roberts; Dr Tim Smith; Dr Ruth Wiggans; Dr Rebecca Wilson; Dr Marcus Baw; Dr Rachel Taylor

Sir, If we as the medical profession strike, it will be the patients who suffer. If we as the medical profession do not strike and the contract is imposed, it will be the patients who suffer. It is now the responsibility of anyone who is or has been or will be a patient, anyone who knows a patient or a prospective patient, to stand up to the government and for themselves and their families. A strike is not the answer, but neither is the alternative.

S Shankar
General surgical registrar, Oxford

Sir, Junior doctors represent the future leaders of our NHS. Their current contract, however, is out of date and is unfair to doctors — a view supported by NHS Employers and the BMA. We have accepted the BMA’s assertion that a new contract is required that better protects doctors and patients, promotes a good quality of life, and ensures that doctors have more stable earnings. There are a few misunderstandings that need to be cleared up, however. Junior doctors will not see dramatic reductions in their earnings, as the government has made it clear that no savings are being sought from the pay bill for junior doctors.

We have no intention of reducing GPs’ pay and we will use pay premiums to help to attract doctors into the specialties with the greatest shortages. Finally, a new contract will provide greater safeguards regarding hours of work, not less.

Danny Mortimer
Chief executive, NHS Employers

Sir, The government has suggested that the hours between 7am and 10pm Monday to Saturday would represent “normal” working hours for junior doctors. This is perplexing, as MPs do not sit before 9.30am, have an average finish time of 7pm and sat for a total of 989 hours last year — the lowest figure since 1979.

Not only this, but they receive a meal allowance if they work beyond 7.30pm and a free taxi home if they work beyond 11pm. Parliament finishes early every Friday and has only sat four times on a Saturday since 1939. Maybe we are not all in this together.

Dr Anthony Cohn
London NW4

Addenbrooke’s hospital is just the canary in the coal mine as far as the NHS is concerned

Its going to get worse. Local CCGs and Health Boards will attempt to restructure and reconfigure to make savings. Doctors and Nurses will be re-applying for their jobs. Redundancies will be encouraged. No change will occur without the open debate that Mr Stevens called for. Exit interviews should be encouraged and gongs should be awarded to those who speak out, rather than those who keep quiet and wont “rock the boat”.

Benedict Cooper for The New Statesman 23rd September 2015 opines: Addenbrooke’s hospital is just the canary in the coal mine as far as the NHS is concerned

A toxic cocktail of under-pressure local authorities and low staffing has the NHS on the brink.

Among the grim litany of charges laid out in the Francis Report into the Mid Staffordshire scandal, time and again short staffing came up.

“It should have been clear,” the report said, “from the history and the nature of the deficiencies being reported, particularly in relation to staffing, that a dangerous situation had been allowed by the Trust leadership to develop and that urgent action and intervention were required”.

It went on: “The complaints heard at both the first inquiry and this one testified not only to inadequate staffing levels, but poor leadership, recruitment and training”.Two and a half years later, have the lessons of that dark episode been learned? Today’s Independent would suggest not. It reports that out of 89 acute hospitals inspected between 2014 and 2015, three quarters raised concerns over staffing levels.

Yesterday Addenbrooke’s Hospital in Cambridgeshire became the latest acute hospital to be branded “inadequate” by the Care Quality Commission (CQC) and the trust that runs it placed into special measures.

“Inspectors found a significant shortage of staff in a number of areas including critical care services,” the CQC said in a statement. “This often resulted in staff being moved across different services, with gaps back-filled by bank or agency staff.

After the long recess, it’s always a good time to reflect. Just as Parliament broke Jeremy Hunt was facing a backlash from, well, most of the medical profession, crystalised in the #iminworkjeremy and #weneedtotalkaboutjeremy social media campaigns; the King’s Fund’s Quarterly Monitoring Report in July revealed the highest A&E waiting times for a decade, 66 per cent of trusts forecasting a deficit by the end of the financial year and staff morale being the biggest concern for trust finance directors; the share of spending on GP services as a proportion of the overall NHS budget has fallen again; local authorities have been handed another £1.1bn of cuts; and a third of CCGs are now considering rationing – aka cutting back – services.
For a government which spins itself as the saviour of the NHS, it doesn’t look good. Especially when you look at the Addenbrooke’s case in more detail. Last year the hospital was awarded top marks by the CQC – I’ll just let that sink in. In May last year Addenbrooke’s passed with flying colours; yesterday it was ranked ‘inadequate’.

What could have possibly changed at one of the country’s top hospitals that it should decline so alarmingly in such a short space of time? Retired senior nurse and National Health Action Party member Hilary Price, who worked in the Cambridgeshire area for 40 years, tells me Addenbrooke’s has been the victim of a “pincer movement” of underfunding and regulation that has brought the trust to this point.

She says: “On the one hand, the CQC is criticising underfunded clinical care, whilst, on the other hand, Monitor is expecting the hospital to further constrain its expenditure, which will only exacerbate the problems identified by the CQC. The Government is withholding essential funds from Addenbrooke’s, instructing it to make untenable cuts, year on year, misnamed ‘efficiency savings’, whilst still expecting it to deliver safe, high quality services”.

It’s a familiar picture. With two-thirds of trusts forecasting a deficit, despite in all cases having already made significant ‘efficiency’ savings, the pressures on frontline services and frontline staff have gone beyond intense.

Unite national officer for health Barrie Brown says that the failings revealed by the CQC can’t be taken in isolation, nor should the trust take the rap.

He says: “The problems identified by the CQC reflect failures in workforce planning across the NHS; they’re not the direct responsibility of Addenbooke’s which is the victim of this failure. The overwhelming pressures on local authority care budgets cannot be dealt with by Addenbrooke’s, despite the implication of Professor Mike Richards who cites other hospital trusts doing that.

“What account has been taken of the CCG’s commissioning and payment for services against the backdrop of significant increases in healthcare demands, made more difficult due to the tremendous reputation of Addenbrooke’s for clinical excellence?”

The government isn’t flinching from its programme of enforcing £22bn of cuts on the NHS, nor from the planned evaporation of funding for local authorities, heaping even more pressure on hospitals – it was cited by the Commission on acute adult psychiatric care in England as the primary reason for delays to discharges from mental health wards. The UK has one of the lowest beds-per-capita ratios in the developed world – 2.95 per thousand people compared with 8.27 in Germany, and the ratio of spending on healthcare is set to fall from around 8 per cent of GDP –the second lowest in the G7 – to 6 per cent by 2020.
When the new general secretary and chief executive of the Royal College of Nursing (RCN) Janet Davies took up her post in August, she came out fighting for her profession in the starkest possible terms. Staff shortages and the pay restraint are threatening lives, she said, forcing nurses to resort to payday lenders and foodbanks, driving staff out of the profession and severely overstretching services. “This is not a great place to be”, she said at the time.

The truth of Davies’ words is all too stark when I speak to a local source in Cambridgeshire, who tells me that she sees “senior nurses at Addenbrooke’s taking sick leave with stress”. “There are people who are telling me they’re burnt out, and they’re only in their 30s”.

Stafford Hospital stands as dark monument to what can go wrong at a hospital. With 68 acute hospitals between 2014 and 2015 reporting serious concerns over staffing and the words of the Francis Report still echoing around the corridors and wards of hospitals throughout the country, the fear is now that we return to the dark days of the Stafford Hospital scandal, on a wholesale level. The warnings are there, for all to see.
Benedict Cooper is a freelance journalist who covers medical politics and the NHS. He tweets @Ben_JS_Cooper.

The survivor:

NHS truths that dare not speak their name – The name is rationing.. Without it the health services are not safe in any hands..

Nigel Hawkes in the BMJ 22nd September 2015 opines in “NHS truths that dare not speak their name”. BMJ 2015;351:h4983 The name is rationing.. Without it the health services are not safe in any hands..

Trying to make political capital out of the NHS is risky. If the effort fails—as it did for the Labour Party in this year’s general election—you are left opening and closing your mouth with nothing much to say.

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Labour’s bid to “weaponise” the NHS was a dismal failure. Nobody seemed to care that much. The claim that the Conservatives were planning to privatise the service fell on even deafer ears. The NHS Action Party fielded a dozen candidates and polled fewer votes in total than the majority won by the health secretary for England in his South West Surrey seat. Opinion polls indicated not only that electors were tolerant of austerity, they actually welcomed it.

The result has been to close the book for the moment on the default position held by many in the NHS—and even more of its supporters outside—that more money is the answer to its problems. It doesn’t make this position wrong, but it makes it harder to voice. Hasn’t the government already promised £8bn (€11bn; $12.3bn)? Isn’t that enough? Not unless another £22bn can be saved by 2020 from budgets that are already bust, and nobody actually believes that this is likely. Likewise, very few people except those whose jobs depend on it believe that NHS vanguard projects1 will transform care in the present parliament (if ever) or that forming hospitals into chains will cut overheads and standardise services in a way that has eluded every previous effort. Or that NHS Improvement (the product of the enforced coupling of the regulator Monitor and the Trust Development Authority) will actually generate much improvement.

Politics of desperation

Like a drowning man grasping at a straw, the NHS in England is currently prey to the politics of desperation. The financial regulators apparently believe that the total deficit in acute care trusts—£2bn this year and rising—is the result of trusts not trying hard enough, while the trusts say that they can do no more without affecting services. Hunt has clamped down on agency staff spending, but if trusts cannot find enough permanent staff to fill the gaps, failures of care become more likely. Continuing restraint on pay, another Hunt demand, makes agency work more attractive: reliance on agency nurses doubled from 2012 to 2014. Many NHS workers get the best of both worlds by having a staff job and taking agency work on the side, sometimes in the very same hospital.

The peer Patrick Carter, who has been charged with finding efficiency savings in trusts,2 says (his fingers crossed behind his back) that there may be £5bn a year to be saved. It’s impossible to tell whether he is right, as this figure isn’t evidenced, and realising the savings is the hard part. The NHS has travelled this road before many times, most recently in Better Procurement, Better Value, Better Care, a strategy published as recently as August 2013.3 That aimed to save a more modest £1.5bn by 2015-16. Did it succeed? Apparently not, since we heard no more about it.

I could fill this column with hard to believe claims. They’re everywhere, and they mostly go unchallenged, because even the most determined nay-sayers eventually begin to tire. So I’ll leave you with one more. On 2 September, at the Health and Care Innovation Expo in Manchester, Simon Stevens, chief executive of NHS England, announced “a major drive” to improve health in the NHS workplace.

To pay for this he promised £5m. Since the NHS employs 1.3 million people, and a lot of them are overweight and unfit, this is a conceit of loaves and fishes dimensions. For £5m all we’ll get are action plans and frameworks, as if talking about it were a substitute for doing it, until the whole initiative dribbles away into the sand. Meanwhile the chancellor of the exchequer has cut £200m from local authorities’ spending on public health.

I can’t improve on a comment recently attached to an article in the Health Service Journal about the vanguard sites. It read, “Somewhere there ought to be an NHS Museum of Pointless Initiatives, where every centralising, witless progenitor of Another Damn Good Idea That Will Save Money After Costing Some should be forced to spend a week or two in silent contemplation before being allowed to proceed with their heroic pilots and their leaden roll-outs and their oddly (but invariably) much quieter windings-up.” I’d like to credit the author of this outburst, but, as is invariably the case with the more entertaining comments in the HSJ, it was anonymous.

Tigers of improvement

There are of course inefficiencies in the NHS against which the new tigers of NHS Improvement are soon to be unleashed. But international comparisons don’t indicate that the situation is hopeless. The service costs rather less than that in similar European countries and a whole pile less than in the United States, whose ideas we are increasingly importing.

The regular comparisons by the US think tank the Commonwealth Fund show that the NHS does well on access, equity, and efficiency, less well on outcomes.4 These reports have been a handy prop to health secretaries under fire—even Hunt has quoted from them—and while they don’t quite prove that the NHS is the best in the world (they record only one outcome measure, deaths amenable to healthcare, where the NHS comes nearly last) they do suggest that it’s decent value for money.

Will the current flurry of initiatives make it better value? Some of them, such as the new models of care being piloted in the vanguard sites, make sense only with a reformed payment system that ceases to reward the volume of activity in acute care. But, like money, nobody wants to talk about that, because large scale reform has got itself a bad name. We’re stuck in a world where the things that might make a difference are the truths that dare not speak their name.

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Doctors without borders.. Some junior doctors consider a strike, while others pack their bags. Almost 3,500 NHS doctors have started the process of moving abroad …

The irony of a government that believes in market forces is that it is subject to distress caused by successive governments training too few doctors at graduate level. An indictment of the short termism inherent in our first past the post political system.  Deliberate rationing by undercapacity.. Update 27th September Denis Campbell in the Guardian 26th September: “Thousands of NHS doctors apply to be able to work abroad amid contract changes”.

The Economist on September 26th 2015 reports: Health care and emigration Doctors without borders Some junior doctors consider a strike, while others pack their bags

JUNIOR doctors in England are threatening to strike, in response to a new contract the government is trying to impose from August 2016. It is easy to see why. At the moment, any doctor working from 7pm to 7am on weekdays, or any time at the weekend, is considered to keep “antisocial” hours. They are rewarded with a higher rate of pay. Under the proposals, “social” hours are being extended, to include any time before 10pm, Monday to Saturday.

The change would wallop junior doctors, for whom pay outside their basic hours makes up one-third of their overall packet. NHS Employers, an industry body, has not provided many data, and the changes will affect doctors differently, but some could see a 20-40% pay cut. This would reinforce a secular decline in “real”, or inflation-adjusted, pay (see chart).

Like workers in any public service, doctors always say that morale has never been lower. But this time many are threatening to vote with their feet and practise overseas. Normally the General Medical Council, which regulates the profession, gets 20-25 requests a day for certificates of professional status, which make it easier to work abroad. From September 16th-18th it received a staggering 1,644 requests.

A small number of doctors went on a 24-hour strike in 2012. Many were in senior positions and continued to perform essential tasks. A study by Imperial College London found that the strike led to no increase in in-hospital deaths on the day. But it is trickier for junior doctors to pick and choose, since they are more likely to be dealing with emergency situations. One junior doctor says going on strike was previously “unthinkable”. No longer.