One way to manage decline is to catalyse and facilitate the loss and downgrading of staff. The staff are the Minister’s most valuable asset, but he and his predecessors have failed to show this over a number of terms of office. Reversing the disengagement and lack of trust will need time and skills beyond the present administration. NHSreality feels we have gone beyond the point where small adjustments could reverse the cultural disintegration and fear…..
BRITAIN’S top surgeons have warned that new government contracts for junior doctors may accelerate the “brain drain” stripping the NHS of its most talented staff.
In a letter urging Jeremy Hunt, the health secretary, to re-engage in talks to avert a strike that could delay up to 180,000 operations, more than 1,000 consultants sound the alarm about the falling number of applications to medical schools and rising dropout rates.
Three days of walkouts are set to disrupt non-urgent NHS services next month after 98% of the 28,305 junior doctors who took part in a British Medical Association (BMA) ballot backed strike action.
Hunt has said the new contracts are necessary to provide a seven-day NHS and that a reduction in overtime rates for junior doctors at weekends would be compensated for by extra basic pay and a cut in the maximum number of hours a doctor can work in a week.
He has accused the doctors’ union of misleading its members, but the BMA says the government is trying to impose an unfair contract because some doctors’ pay would drop.
In the past two days more than 1,000 consultant surgeons have added their names to the letter, published today in The Sunday Times, urging NHS employers to “restart negotiations without the threat of preconditions or the imposition of the new contract to avoid further threats of industrial action”.
Among those who signed the letter is Nigel Standfield, a vascular surgeon and head of the London Postgraduate School of Surgery, which is responsible for 1,400 trainees.
He said: “These figures are hugely alarming, especially given the amount of money that has been invested in their training.
“The competition ratios for jobs are now so low that we are unable to maintain the high standards required and this is causing immense pressure on the hospital environment.”
In 2007 there were eight junior doctors competing for each surgical speciality post but now the ratio is just one to one, according to BMJ Careers.
Shafi Ahmed, a council member of the Royal College of Surgeons, said hospitals were struggling to fill posts as trainees dropped out or moved abroad.
This year 8,026 doctors have been issued with a certificate of current professional status, the paperwork needed to practise medicine outside the UK, against 4,564 in 2008.
Ahmed said: “We are seeing a shortage of trainees and if the new contract goes ahead we face an even bigger exodus. Junior doctors have the right to strike but we are urging both parties to go back to the table.”
Consultants argue the proposed changes would see trainees “paid less to do extra hours, out of hours” and that those who took time out to do research or to have a family would be hit hardest.
Stella Vig, a consultant vascular surgeon and chairwoman of the joint committee on surgical training, said: “Female surgeons will naturally take career breaks to have children but the proposed pay structure discourages this.”
Alistair Burt, a health minister, said Hunt had not ruled out mediation through the conciliation service Acas.
He said up to 60,000 operations would be at risk of cancellation or delay on each day of strike action and described the industrial action, planned for December 1, 8 and 16 as “entirely avoidable”.
The Department of Health said: “Strike action always puts patients at risk so this blinkered and persistent refusal by the BMA to engage with the government is extremely disappointing.”
Junior doctors will provide a “Christmas Day” level of service on the first day of the strikes and a full walkout on the second two days from 8am to 5pm.
Several trusts have said they will ask consultants to cancel elective work in order to cover emergency care.
Dr Kathy McLean, medical director at the NHS Trust Development Authority, said: “We will be working with NHS England, trusts and foundation trusts on plans to manage the impact of industrial action and minimise disruption for patients where possible.”
Prescribing a fair deal for junior doctors
Dear Rt Hon Jeremy Hunt MP,
We, the undersigned, write to you as concerned consultant surgeons, surgical trainers and patient advocates. The current pressures facing the NHS are immense and we are working hard, despite the acute and massive underfunding of clinical services, to provide safe and appropriate care to our patients. Large amounts of NHS monies are being wasted on unnecessary and expensive tiers of management. Despite this being an obvious place to start with reorganisation of contracts, the minister of health has chosen junior doctors. We suggest that the entire NHS and its staff have to support our junior colleagues through their endeavours to become our consultant colleagues of the future.
We are as confused as they are to the need for the proposed changes in their contract.
We currently provide a seven-day emergency service. We have improved this provision by the introduction of national emergency standards, implemented since 2011. We understand the advantages of using endoscopy suites and operating theatres and providing elective services over the weekend, but this requires far more than junior doctors and ourselves. It would be necessary for the entire establishment to work on a seven-day basis, including clerks, cleaners, nurses, plaster technicians, operating departmental assistants, physiotherapists, specialist nurses, pharmacy and all the laboratories, as well as many more.
Do the public wish these services provided on Saturdays and Sundays? “No,” is what we are hearing.
There is a shortage of junior doctors at present and we understand that applications to medical schools have fallen this year. In addition, 40% of trainees from 2014 did not continue from the foundation programme to the next stage, ie a speciality or GP recruitment. Some have given up a medical career and many are choosing to travel overseas. This exodus is highlighted by the numbers of trainees requesting Certificates of Good Standing from the General Medical Council. The competition ratios between core (years 3 and 4, post qualification) and speciality recruitment are now an unprecedented 1:1, having been approximately 8:1 before the catastrophic reorganisations such as MTAS (Medical Training Application Service) in 2007. Each attempt at reorganisation is poorly thought through, short-term and ill-advised. They are making the situation worse.
Core surgical training is the provider not just of trainee surgeons but also of A&E doctors, interventional radiologists, GPs, researchers and teachers, as well as many others. In addition we have attracted many female junior surgeons through initiatives such as Women in Surgery. Many of these groups appear to be discouraged into these career pathways due to the terms and conditions of the proposed new junior contract.
The removal of the current hours monitoring raises concern of a return to pre-European Working Time Directive days, where there were many exhausted doctors providing service rather than being trained. The proposed rotas, required to make the new contract work, will undermine surgical training. Currently we train our junior colleagues to provide an independent excellent level of service at the end of training. This is in parallel to the delivery of clinical services and centrally determined managerial targets.
We also currently have an unprecedented shortage of nurses. The national policy set up by the minister of health to move healthcare into the community and to create 5,000 GPs by 2020, has resulted in the block removal of foundation trainees from surgery and transfer into general practice. The plan to replace them with nurses performing roles previously fulfilled by doctors is backfiring. It is leaving the remaining junior doctors overworked and the nursing establishment perilously short.
There is an increase in the number of demoralised trainees within a difficult NHS environment. They experience first-hand the lifestyle of consultants and, perhaps even more damaging, the constant undervaluing and undermining of NHS professionals. Many leave after completing years of training.
The junior trainees – a misnomer, as many are training for six years prior to graduating – carry a large debt into training, often in excess of £50,000. In addition they then train for four years to develop registrar status and another six to complete their training. This is as an understanding that surgical training is practical and experiential (needing knowledge as well as technical skills), and unlike medical training cannot be easily shortened.
Millions have been wasted on reorganisations, competition, contracting of services to the private sector and the creation of new organisations within the NHS with further bureaucracy, which have destabilised the hospitals in which we are established. Reducing junior doctor pay – as surely these changes cannot be offering a pay increase if the pay envelope remains a constant – is a poor policy decision, as it hits a hardworking, dedicated and essential workforce within the NHS. The entire reason for introducing overtime payments in the first place has been hidden from scrutiny: it was not to reward trainees for working exceptionally long hours, but to punish unscrupulous trusts for exploiting junior trainees by forcing them into working excessive rotas.
Trainees, in close partnership with us, their consultants, deliver essential frontline care.
We strongly suggest that NHS employers restart negotiations through a mediator without the threat of preconditions or the imposition of the new contract, to avoid further threats of industrial action. This is unprecedented. It is the action of an altruistic workforce who feels that it has no other option but to take drastic action.
We fully and unequivocally support our trainees and will ensure that their voices are heard, without compromising the safety of patients under our care.
Professor Nigel Standfield, professor of vascular surgery and head of London Postgraduate School of Surgery; Shafi Ahmed, consultant-general, laparoscopic and colorectal surgeon; Stella Vig, consultant vascular and general surgeon, South London core and higher surgery programme director; Rhiannon Harries, president of the Association of Surgeons in Training; Mustafa Rashid, president of the British Orthopaedic Trainees Association
NHS LAID LOW BY COMMISSIONING MALADY
The dispute over junior doctors’ contracts and the government drive for seven-day working are distractions from the problems of the NHS (“Nobody will gain from this doctors’ strike”, Editorial, last week).
Nine out 10 hospital trusts are in financial deficit. At a time when the NHS is being asked to find £22bn in efficiency savings, huge sums are haemorrhaging through the present complex system of commissioning healthcare. The process of negotiating contracts for services in the so-called internal market has been estimated to consume 14% of the NHS budget.
This was before Andrew Lansley’s Health and Social Care Act — itself said to have cost up to £3bn — which further increased the requirement for competitive tendering.
The changes were supposed to reduce bureaucracy but the opposite has happened. Commissioning healthcare is carried out by 211 individual commissioning groups, each with its own infrastructure.
Many of the most able GPs are taken up with commissioning. Many doctors are retiring early to escape from the blame culture prevalent in the NHS.
Professor Robert Elkeles, Northwood, London
Why is it that the emergency services are always held over an emotional barrel when it comes to strike action? Firefighters, police officers and doctors risk injury on a daily basis. My daughter is a doctor and while in A&E has been stabbed twice, and suffered verbal and physical abuse, but somehow she is prevented from exercising her civil rights when she has to suffer a 30% pay cut.
Merenda Longshaw, Fleet, Hampshire