Three Strikes and You’re Out

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The first junior doctor strike for 40 years is imminent.

A staggering 98% of votes, or about 28,000 junior doctors out of 28,600 supported strike action (there were also some who didn’t vote, or weren’t eligible to vote). Jeremy Hunt is putting on his best bemused face, claiming that doctors have been misled by the BMA or by a militant faction, and that his offer-that-can’t-be-refused is actually a good deal for all parties.

And some people who have been supporting junior doctors are wavering when faced with the prospect of a strike. This includes Heidi Alexander, the shadow health secretary, who has spoken out against a doctors’ strike. Chuka Umunna, thought of as a possible future labour leader, refused to endorse strike action on Question Time, saying that he couldn’t support something that might harm his constituents.

And therein lies the slight, niggling concern that is afflicting many junior doctors right now. Because we do care about our patients. We do take pride in our work. And however well our consultant colleagues cover for us, we can’t help worrying that some people will be harmed by our actions.

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Here’s a quick breakdown of the pros and cons of strike action.

What have the strikes already done for us?

In July, Jeremy Hunt launched his push for the “7 day NHS” promised in the Conservative manifesto with a salvo against the “Monday to Friday culture of the NHS”. He blamed lazy consultants refusing to work weekends for thousands of excess deaths. His claims were reported as facts by the media, although they are highly questionable. There was a huge social media backlash from doctors, in particular with the hashtag #IminworkJeremy. But this response did not get picked up by the press for months. Likewise, the junior doctor’s contract saga has been rumbling on for years, without breaking through to the mainstream media. There is absolutely no question that the threat of strikes have forced this issue to the front of the national consciousness, to the front pages of the media, and to the front of Jeremy Hunt’s priority list.

And with the groundswell in publicity, and much public support, have come some concessions from the government. The concessions have spun not as concessions but simply as previously unmentioned facts. For example, when Jeremy Hunt announced in the parliamentary debate on junior doctors that no junior doctor would lose out through the new contract, he said it as if this had always been the plan. In fact, what he was announcing was pay protection for current juniors, so that if the new contract gave them a pay cut their old salaries would apply until 2019. This was not part of the original offer, and it does help a bit. For example, one concern with the new contract was that doctors would suddenly not be able to afford their mortgages. Now, their pay is protected for another three years. And it is significant too in terms of cost. Because if you increase some salaries, but guarantee no-one loses out, you must increase the overall pay envelope temporarily. So, cost-wise, Hunt is prepared to break his own rule of a neutral pay envelope for a few years, in order to get what he wants in the long term. Of course, this offer doesn’t address the problem of pay-cuts for some specialties with the new contract, it just defers them for three years.

Another concession relates to the “preconditions” affecting the putative contract negotiations. Originally, the government view was that the contract must be based on the hated DDRB report. Now Hunt says he’s much more open, although he still insists that the new contract must deliver his mythical 7 day services, and be overall cost neutral compared to the current contract. And he still insists if there is no agreement he will impose his contract.

Neither of these concessions, which are both significant, have been advertised as such, prehaps because acknowledging them as concessions would seem like a confession that his original position was flawed. Meanwhile, his most publicised concession, the “11% payrise offer” made via the media, was not a concession at all. This increase in basic pay was less than what was originally suggested by the DDRB, and would be paired with a reduction in other pay, keeping the whole payroll for junior doctors cost neutral. Calling this a payrise is not spin, it’s a lie.

The latest concession has been an agreement to allow ACAS to mediate in the dispute.

What more can the strikes do for us?

The BMA has been admirably clear what they want from the Government. They want removal of the threat to impose a contract that doctors don’t agree on, they want strong safeguards to prevent doctors working crazy hours, they want adequate pay (which does not mean, and never has meant, a payrise), they want people working part time or taking time out for research or family reasons not to be disadvantaged, they want people working unsocial hours not to be disadvantaged.

The Government has given some ground. There is some chance that with a bit more flexibility some or all of the strikes could be averted. The increasingly imminent threat of a strike, or perhaps the first “emergency cover only” strike might just be enough to tip the balance, and lead to a Government retreat.

The best case scenario for all parties would seem to be a return to negotiations, with the Government stepping back from its inflexible position and putting all options on the table. And they would have to remove the threat to impose a new contract that is not accepted by junior doctors.

Of course, there are deep currents in the political world, and some have suggested that a strike by doctors would actually help the Government in some ways. It might help them to justify and push through Parliament stronger anti-strike legislation. It might help for them to justify further NHS reforms. It might be seen as an opportunity for someone in the Conservative Party to show off their leadership potential ahead of a likely leadership battle in the coming years.

If all three strikes go ahead, it is difficult to guess how public opinion might be affected. Some people may well support the doctors. But others will not. And if the dispute carries on to even more strikes, public goodwill might be severely tested.

What will the strikes do to patients?

Doctors’ strikes are a surprisingly common phenomenon, worldwide, and there’s a fair amount of research looking at how they affect death rates. And the studies are reassuring – death rates stay stable, or even sometimes decrease, during strikes. The most obvious reason for this is that elective procedures are cancelled, and these do carry a risk of death. This is the same logic that explains why, despite what you read in the papers, weekends are a relatively safe time to be in hospital. Another thing that might contribute to decreased death rates if junior doctors strike is that the work is covered by consultants, who are more experienced than the trainees they are replacing.

There’s a nice piece in the BMJ reviewing the data on doctors, strikes, and death rates.

But death rates during a strike do not tell the whole story. They don’t cover the anxiety caused to patients even if their care is not eventually affected. They don’t cover the delays to outpatient appointments when clinics are cancelled. They don’t cover delays to surgery when surgical lists are cancelled. They don’t cover the distress caused when tests or test results are delayed. And in some medical conditions a delay in diagnosis or treatment can cause serious harm.

Even if death rates don’t go up during the strike period, patient care will be affected.

What will the strikes do for the NHS?

Junior doctors are an important part of the NHS. And so are the nurses, physios, radiographers, pharmacists, occupational therapists, nursing assistants, tea-trolley pushers, porters, receptionists, secretaries and the managers and executives. And if you ask anyone who has worked in the NHS for the past few years, they will have noticed a change. Spending has been frozen, while demand is continually increasing. That tension is the reason that almost all NHS trusts are in the red, including some at the forefront of clinical achievement. That is the reason that waiting times are rocketing, and Government targets that have been met for years are suddenly impossible to achieve. Budget constraints are the reason that recruitment is low, since hospitals can’t afford to fill vacancies. Doctors and nurses have become increasingly used to turning up to work to find that colleagues are missing because rotas are understaffed.

An organisation under this kind of pressure is not a fun place to work, especially at a time when your pay is frozen and falling in real terms. Doctors, and other health professionals with transferable and valued skills, have been haemorrhaging out of the NHS for years.  Retention rates for junior doctors are dropping year by year. And there are appealing alternatives elsewhere.

That is the background against which the current dispute is playing out. And if the current crop of junior doctors just lie down and take an even worse deal, where does that leave the future of the NHS? Striking seems like a way to halt the decline, while accepting the new contract seems like a way of accelerating it. Other health professionals have been vocal in supporting the junior doctors, because they feel that they are next in the Government’s line of fire.

That’s why it’s worth asking not just what harm the strikes will do in the short term, but also what harm NOT striking will do in the medium and long term. Whatever course of action doctors choose, there are likely to be patients who suffer.

What happens next?

Surely both the Government and the BMA must share a desire to see patients receive the best care possible? And that purpose can only be achieved by a contract that is appealing to current and future doctors, as well as acceptable to those holding the purse strings.

With the threat of a contract that everyone hates, a majority of junior doctors supporting strike action, and a sense of unity in the profession that surprises even us, I can’t see the doctors backing down.

The Government has already taken some steps backwards, and a few more steps of retreat could get everone back to the negotiating table. That’s the sensible option, and that’s what I believe will happen. How long it will take is tough to predict.

But junior doctors walking away from the NHS for three days is better than junior doctors just walking away…

 

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