Brexit, junior doctor contracts and the Tory-DUP deal - a perfect storm for junior doctor morale

By MedShr, 2017

 

With the latest political war over, the dust will now begin to settle, talk will turn back to celebrities and frivolity, and the NHS will continue on its current trajectory with Hunt at the helm. But what does the new government mean for the NHS - and in particular the current state of morale for junior doctors?

 

The morale of NHS doctors has been a concern for many years, and results from the latest NHS staff survey show that 39% of NHS staff admitted to experiencing work-related stress that made them feel unwell in the last 12 months (NHS Staff Survey, 2016).

 

Why are junior doctors suffering from low morale?

 

Let’s start with Brexit. In 2016, 10% of doctors were from elsewhere in the EU according to the English Health Service’s Electronic Staff Record. If Brexit negotiations turn sour, and EU citizens can’t be guaranteed their rights within the UK - or in fact just don’t feel welcome anymore - we would face an NHS staffing crisis amongst doctors. The BMA polled over 1,000 doctors from the EU working in the NHS after the Brexit vote, and found that 42% are thinking of leaving, and a further 23% were unsure (BMA, 2017).

 

And then there is the 1% pay cap that was introduced by the Conservative government, which means that with inflation, staff are actually getting paid less year-on-year. This is simply an insult to the people we are entrusting to save our lives, and was exacerbated by Theresa May’s unsympathetic comments during the election campaign that there is “no magic money tree.” Real term pay cuts for doctors and nurses are having a direct effect on recruitment and retention across the NHS.

 

Next is the workforce crisis that is hidden from public view. Already thinly stretched, junior doctors are reporting gaps in rotas and regularly working longer than their allocated hours to protect patient safety and complete essential clinical work. These excessive and often unrealistic workloads, coupled with falling pay, are pushing doctors to leave medicine. The Royal College of Physicians (RCP) even issued a warning at the end of last year that patient safety was seriously compromised by gaps in junior doctor rotas. For example, in paediatrics, the most recent workforce report shows hospitals are currently having to cope with an average junior doctor vacancy rate of 14% and 240 empty consultant posts (Politics, 2017).

 

And finally, the lack of recognition. Politicians talk about increased spending and promises about recruitment to the NHS, but what we must remember is that these pledges affect real people; people who are doing their best to keep us safe. Junior doctors are at the start of their careers, but face low morale and the risk of burnout from year one, so it’s no wonder they are leaving to work in sunnier climates with better working conditions (BMA, 2016).

 

What can we do about low morale?

 

We need to start focusing on the health and wellbeing, both mental and physical, of those who look after ours. Nearly all political parties promised an increase in NHS funding. More resources and increased staffing would mean that junior doctors will feel less stretched, causing less work-related stress and ultimately improving morale - but with an ever-increasing population, is the UK government willing to put up taxes to pay for it? Is the NHS as efficient as it can be, and if not, what streamlining and collaboration can be introduced to improve services and reduce the workload on junior doctors?

 

The NHS under the Conservative-DUP deal

 

During their 2017 election campaign, the Conservatives pledged to support GPs in delivering “innovative services that better meet patients’ needs, including phone and online consultations and the use of technology to triage people better and support integrated working.” However, they also want all newly qualified doctors to be forced to work for the NHS for at least four years - a form of indentured labour which is highly unlikely to make doctors feel valued and may exacerbate the antipathy.

 

Could the Conservatives’ health policies be the reason May failed to gain a majority? And will the DUP block or support the Conservatives in their healthcare plans? In 2016, the DUP released a document that states they believe that the NHS needs to evolve to fit 21st century patients and societal problems, an NHS that is “more efficient, more productive and embraces innovation. One that realises the full potential of our integrated health and social care systems” (DUP, 2016). This could mean that a Tory-DUP deal will attempt to streamline NHS pathways and improve efficiency between primary and secondary care. But is this even possible without a significant increase in funding and resolving the lack of morale that is currently rife amongst overworked junior doctors?

 

The literature and first-hand anecdotes are out there, and it’s a well-trodden mantra - the NHS is underfunded. Without increased funding, there simply will not be enough staff, and junior doctors will continue to feel overworked and undervalued. And without junior doctors staying to progress within the NHS, there may not be a free NHS forever. Aneurin Bevan – often credited as creating the NHS - said in parliament on February 8th 1948, “take pride…we are still able to do the most civilised thing in the world, put the welfare for the sick in front of every other consideration,” - but perhaps we no longer are.

Arrival of the in-laws.

Posted by mumormedic June 29th 2017

So, deep breath, the in-laws are coming today. Don’t get me wrong, I’m actually very lucky and could have done a lot worse in the in-law stakes, they’re kind, considerate, care about the boys and are willing to help if they’re able to (given my FILs ill health and the fact they live on the opposite side of the country this is somewhat limited, but the offer is there for occasional help.). Having said that the whole experience is always somewhat stressful.

My mother in law and I are very different (or maybe I wish we were very different, but actually we’re quite similar, don’t they say something about men marrying a woman like their mothers?). MIL was a full time stay at home mother who raised 4 children who did every extra curricular activity under the sun and, kept an immaculate house (and still does), her children always wore ironed clothes, they had an open house policy and the children always had friends over to play and for tea and her children all excelled at school, played several instruments, partook in multiple sports and could speak more than 1 additional language and this was all from having gone to the local village school. MIL didn’t require any additional help and did all this on her own and loved every minute of it (as we frequently hear). I, on the other hand, work 0.6% FTE and my husband is a full time medical registra. To try and make the work/children/life juggle work I’ve recently given up on trying to be superwoman and despite lack of finances have just thrown money (we don’t have) at the problem. We now have a cleaner, ironing lady and nanny. Despite this my house rarely looks clean, except possibly in the one hour after the cleaner leaves and before the boys get home, the children still don’t wear ironed clothes (but at least I now look less like I’ve just rolled out of bed) and I certainly don’t have an open house policy, in fact I don’t have enough fingers to count on the number of play dates we owe people. Luckily 5 year old boy is popular so despite having a mother who rarely finds time to host a play date, he seems to get invited to play at various friends houses on a regular basis.

 

Anyway, back to the in-laws, so having rearranged the cleaner to come today rather than at the beginning of the week like she usually does and ordered an online shop so we’d have food in the house, I got home from work to discover the boys have been playing in the garden with the nanny so their was a trail of sand and soil through the downstairs where they’d come in to go to the toilet, get snacks etc and the food that I’d ordered hadn’t arrived, or at least it had arrived, except the only things that had been delivered were toilet rolls, 6 bottles of wine and a case of beer-thinking about it I vaguely remember logging on, booking a slot and starting the shop a few mornings ago after a night shift, when I decided I was actually too tired to shop properly so I checked out with the plan to come back to it later-oh well, the in-laws will now just think I’m an alcoholic with a toilet problem. Off to the supermarket it is then with the boys in tow and hopefully we'll be home before the in-laws arrive and we won't find them sat on our doorstep on our return.

Austerity in essential public services is deadly. Grenfell demonstrates it. The NHS exemplifies it.

Posted by juniordoctorblog June 18th 2017

“I seem, then, in just this little thing to be wiser than this man at any rate, that what I do not know I do not think I know either..”
Socrates 

Apology by Plato

The events of the last week will undoubtedly shape the future of Britain in a monumental fashion. First, an election like none we have seen for fifty years. Called in hubris, led to nemesis, won, in truth, by no one. History-making nonetheless. The prevailing wind of politics has changed, now blowing Left of centre for the first time in nearly a decade. Corbyn has an approval rating of +6, Theresa May a disapproval rating of -34, nearly mirror opposites of where they stood in November. Who knew?

Theresa May and the Conservatives struck a conciliatory tone. “Austerity is over” they said, in radio interviews, in leaked excerpts from backbencher committee meetings. The “mood has changed” they said.

And then Grenfell Tower happened. And the mood changed again.

As details drip out of what will undoubtedly be known as the biggest domestic disaster since Hillsborough, a hazy but consistent picture coalesces. The fire began reportedly in a fourth floor flat, starting with a fridge. The residents had campaigned for years before about power surges in the building, about the risk of a lethal fire with appliances, but sadly, were ignored. Within minutes, it is reported, the fire had spread out of a window and roared up the side of the tower, consuming the external cladding system as one resident described “like matchsticks”. This external cladding had been part of a recent £8.7 million refurbishment, subcontracted by the private enterprise managing the tower, KCTMO, to update the insulation and aesthetic aspects of the outer structure. In the Times today, it is reported that the cladding material used is illegal in structures greater than 18 metres, is flammable when an alternative fire resistant material would’ve cost just £5000 more, and is illegal in Germany and the USA. Sky News’ Faisal Islam shared a BRE presentation this weekend, a diagram of exactly the kind of disaster that befell Grenfell, dated June 2014, three years ago exactly. In summary, we await the public inquiry that must happen, but it seems 58 (at time of writing) people died in a preventable disaster, that was forewarned, already forestalled in other countries, and seems to have been the result of thoughtless (one hopes) cost cutting from a private company.
But, as Damian Green stated in an extraordinary Radio 4 interview, “we must await the experts”.

Which struck a chord with me.

The mantra “prevention is better than cure” is as true in medicine as it is in fire fighting. Much of what we do, day to day, is about preventing future disease, rather than treating it’s corollaries. We use safety cannulas for preventing needlestick injury, we campaign to stop smoking to prevent lung and other cancers, we screen and treat alcoholics on admission to hospital to prevent deadly withdrawal seizures. When we see impending disaster threatening human life, we have a duty to act, as best we can.

A disaster likely already happened in the NHS, and I cannot help but see the parallels with Grenfell. In February of this year a Royal Society of Medicine Report looked into what was explained away by the government as a “statistical blip.”. Since 2010 the death rate in the U.K. was rising, for the first time in fifty years. More people were dying. To be exact, 30,000 “extra” people died in 2015 compared to what was expected. This study attempted to explain where these extra deaths came from. Was it a subpar flu vaccine one season , as Jeremy Hunt, once and current Health secretary, had claimed? No, the study concluded, the only explanation that fit the data was that 30,000 excess deaths were most likely a direct result of cuts to health and social care services.

Let that sink in.

30,000 men and women, potentially your grandmother or father, sister or uncle, whose deaths were in some way contributed to by cuts to services in the name of “austerity”. Like Grenfell, cutting corners and saving pennies, led to a national disaster. Like Grenfell, multiple agencies have limited oversight over the system as a whole. Yes, the buck stops with the government, but I’m sure they can pass it through any number of government and non-government subsidiaries. Like Grenfell, this essential public service, is sub-contracted in places to private companies, beholden to shareholders as much, if not more, than to the public they are supposed to serve. And like Grenfell, warnings about impending disaster, from “experts” and public alike, have fallen on deaf ears. But unlike Grenfell no one saw these deaths for what they were, a national disaster on a behemoth scale.

Austerity kills. It has already potentially killed 30,000 men and women in health and social care. It has killed at least 58 in Grenfell last week. It has killed thousands of disabled people whose benefits were removed just months before they died. Who knows where else this cost-cutting at any cost has cost lives to save pennies?

If you think I’m politicising this tragedy, you have it backwards. The politics came first, then the tragedy.

Which brings me back to where we started. “Austerity is over” they said. The “mood has changed” they said. As if austerity were always a fanciful choice, a frivolity that was chosen on a whim, as one might decide on a suitable tie, or a wallpaper for the living room. I don’t remember anyone claiming austerity was a “mood” when Osbourne and Cameron were laying waste to health and social care budgets, schools and police funding. Austerity was essential, they said. We have to “live within our means” they said. Except some of us didn’t manage to. Potentially as many as 30,000 of us, our most vulnerable.

So now austerity is over. Was it ever actually necessary? The short answer is no. The long answer is, perhaps for a while, but ultimately still no. Despite what the Mail and Sun has peddled for half a decade, the idea the economy is akin to a household budget is laughable. Pretending we only have control of spending in a government trying to “balance the books” is patently stupid; a government sets it’s own revenues, through tax and VAT, NI and council tax, levies and custom duties, subsidies from other countries, like the EU. Austerity was harmful to our economic recovery. This isn’t left wing socialist claptrap, this is mainstream economics. The IMF agrees as did a large backing of the UK’s top economists. This is economic theory that goes back a hundred years. Any economist could’ve told you that. But of course, we had had enough of listening to “experts” then.

Apparently that’s all changed now.

If we are listening to architects and fire officers again, perhaps we could list to economists and health experts again too, to teachers and police federations. To paraphrase Socrates, wisdom is knowing what one does not know. As a doctor I’ve begun to understand this more and more. Being conscious of the limits of my knowledge makes me safer, means I can operate with uncertainty and know where I need a colleague’s advice, or my boss.

In the age of the internet it seems we now know everything, but understand nothing. For too long we all “knew” that austerity was necessary, that “too much red tape” was throttling business and enterprise, that the NHS was “bloated” and spending “too much money”. Did any of us examine where this “knowledge” came from?

Now we see we knew nothing at all. I hope from these tragedies we can salvage some wisdom.

In an impassioned interview, the MP David Lammy spoke about the “safety net” of schools and hospitals, of decent housing, that is falling apart all around us. Austerity has shredded that safety net, and many have died slipping through the gaps.

Austerity is over, they say. I think we can rebuild this safety net, I hope we can fix the NHS.

But then, what do I know?

Juniordoctorblog.com

To stop doctors ending their lives, we need to hear from those suffering

Posted Ranaana Srivastava 21st March 2017 
The Guardian

The ceilings soar impressively high, the stained-glass windows are exquisite, and the satin-adorned pews stretch majestically to the dignified altar. Amid the silence punctuated by the barest of sobs, I spot doctors whom I have long lost track of. And row upon row of nurses, still tight years later. As we wait for the service to begin, we imagine we are all silently interrogating our memories about each other. Time parted us for decades before we have gathered in such dreadful circumstances.

“I wanted you to hear it from me,” a colleague had said, audibly upset on the phone. I nearly collided with the pavement when I heard.

She was wonderful, the speakers confirm that morning. Her boss delivers an impassioned eulogy about an inspired clinician and a devoted mother to the children who sometimes tagged along on weekend rounds. Her best friend recalls their last conversation that ended with the doctor saying to the nurse, “Go home, don’t work so hard.”

 I wasn't surprised by Four Corners. Bullying in medicine is as old as the profession

Ranjana Srivastava

 

Read more

Her husband quietly expresses gratitude for their years together and grief for the stolen ones. Her parents sit mutely, heads hung low, suddenly and irrevocably aged. A slideshow of pictures, depicting ordinary things – licking ice-cream, dropping off the kids, medical graduation, the first day of internship – suddenly turned unmistakably poignant. The audience is frozen in a horrible dream.

Outside, there is more heartbreak. “We have to say goodbye to Mummy, just us,” the children’s father says softly. We, the gathered, hold our breath lest it makes a sound. Gently, under the flowers she so loved, she is lifted into the car. It’s soon a mere dot on the road. There are refreshments but the crowd disperses awkwardly, wordlessly, not trusting ourselves to speak.

We had known each other well enough in our early days, biding time on endless night shifts, watching dawn break, praying that the nurses would save the next page for the day crew. Later, our lives diverged, each assuming the other was successful, busy and content. The final time I saw her was shortly before she died.

It had been a fractious day; I felt brittle, from a distance she looked happy. What would have happened if we had stopped to talk?

If she had asked, “How are you?” I’d almost certainly have smiled, “Fine.”

And if I had asked, “How are you?”

Could she conceivably have replied, “Suicidal”?

After the gut-wrenching news of her suicide starts the inevitable soul-searching. It was a bad boss. No, a troubled marriage. Parenting had taken its toll. Or her disagreeable colleagues. She seemed so normal in the days leading up to it. No, far from it. She was upset, anxious, disillusioned. The only thing you learn is that for someone who was surrounded by observant and intelligent people, no one really knew much at all. No one knew what went through the mind of a vibrant and capable doctor in the prime of her life, who one day decided that life wasn’t worth living anymore.

The stories you need to read, in one handy email

 

Read more

Unfortunately, this isn’t the first time I have encountered the suicide of a colleague. Some I had known personally; others were brought close through mutual patients, and still others I would never get to meet because they had ended their life before starting a new rotation. In every instance, other doctors did not realise the depth of their colleague’s mental anguish. “I wondered about her but didn’t want to intrude,” someone ruefully recalled. “I didn’t think it was possible,” reflected another.

Four junior doctors have taken their lives in the past six months in Australia. In my busy hospital, I observe a roundabout of students, residents and specialists in difficulty. But how much difficulty? When they say they’re having a bad time, is it a bad week, a dreadful year, or a tortured life? Are they upset about a rejected grant or do they deem their very existence worthless? Forced smiles and tough hides abound in the workplace, where always being “fine” is a badge of honour. This is why it can be so difficult to distinguish doctors who will indeed be fine from those who need help.

There is ample evidence for the high rates of mental illness in doctors, several times greater compared with other professions and the general population. These figures are quoted so frequently at every orientation that awareness should not be an issue. Practically every institution has an employee assistance program that offers confidential help. Some offer free psychiatric evaluation and counselling. And as with other informal medical consults, many psychiatrists will help a colleague in distress, making access to high-quality help less of an issue for doctors than many others.

Armed with knowledge and surrounded by advice, why do doctors commit suicide at an alarmingly high rate?

I sometimes fear it may be because as a profession, we are reluctant to swallow the evidence. And if we can’t accept the evidence we can’t help ourselves or others. We can have an intellectual discussion about anxiety, depression or suicide and we can apply the knowledge to our patients but identifying vulnerability in our own self is altogether different. No matter how many times we hear it, it still doesn’t seem possible that we, or someone like us, could have a mental illness. The consequences seem so vast, the repercussions so numerous that perhaps it’s better to not know the truthful response to “Are you OK?”

Doctors say that the disclosure of mental illness poses a real threat – to license and insurance, career and reputation

Discrimination, bullying and harassment in medicine are unfortunately never far from the headlines, but thanks to brave people who have risked their career, a victimised doctor has more support than ever before. Nonetheless, a career in medicine means always having to keep up with something, whether it’s the latest research, the newest drugs, the next exam or the upcoming promotion. Doctors would like to be perfect at all of these and are genuinely puzzled when life deals them disappointment. It seems ludicrous now but I was dumbfounded when I got my first mark that wasn’t a distinction. Twenty years later, I realised nothing had changed when my registrar failed his specialist exam and told me that “even the walls” were laughing.

When doctors are depressed, their sense of personal failure is compounded by the suspicion that they somehow lack the ability to pull themselves together. The “well” among them can’t understand how the same stressful hospital ward, the same demanding colleagues, the same rocky tenure track can make some of us angry, others sleepless, and yet others suicidal.

In these pressured times, few doctors would be strangers to a variation of the message, “Heard you’re sick. There’s no cover so let us know whether to cancel your patients.” There is no call more disheartening than one that professes to care about the doctor but can seem like a veiled complaint that says, “If you’re sick, we all suffer.” But while it’s quite easy to tell your colleagues you have pneumonia or a migraine, doctors say the disclosure of mental illness poses a real threat – to license and insurance, career and reputation. The diagnosis invokes not only sadness but also ignominy, which may be why there are so few well-publicised stories of doctors with mental illness.

 How doctors treat doctors may be medicine's secret shame

Ranjana Srivastava

 

Read more

For much of my career, I have watched policies, promises and campaigns about combating mental illness and suicide in doctors. Our knowledge is evolving and with it, ways of managing mental illness, but with many lives lost each year, we don’t have the luxury of time.

Since we can’t always read the suffering of our colleagues, humanity in all our professional dealings and concern and compassion for every colleague must be a priority. As well as this, a healthy dose of introspection about how we judge doctors with a mental illness and why we judge them differently, arguably more poorly, than our patients.

When it comes to mental illness, we hear a lot from the experts but not enough from the sufferers. But in fact, nothing would be more welcome than the insights of doctors who have endured mental suffering and worse, been on the brink of suicide. What healed them and who helped them? What could their colleagues have said or done differently at the time? What workplace adjustments would have meant the most? These stories are clearly among us – hearing them could illuminate the dark corners of our understanding and help link theory and practice.

As a profession, we must do more than lament our dead colleagues. Dealing effectively with mental illness and halting suicide among doctors requires curiosity, compassion and practical support. Most importantly, it requires the humility to realise that in the long span of a career, none of us are immune and those doctors whom we help today could end up saving our life tomorrow.

• In Australia, the crisis support service Lifeline is on 13 11 14. In the UK, the Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Hotline is 1-800-273-8255.