Max Pemberton

The wrong cuts

The Health Secretary’s quest for a ‘seven-day-a-week NHS’ is fundamentally misconceived

The wrong cuts
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[audioplayer src="" title="Dr Clare Gerada and Fraser Nelson discuss the row over junior doctors" startat=34]


[/audioplayer]It has long been rumoured that when Jeremy Hunt took over as Health Secretary, Cameron told him to do one thing with the NHS: keep it out of the headlines. Given that the NHS is an enormous institution, the public take an avid interest in it and it is frequently rocked by scandals and financial difficulties, this was no easy task. Until a few weeks ago, Hunt had managed it with aplomb. And then the junior doctor fiasco happened. It has been cataclysmic, one of the worst public relations disasters to rock a government department for years, and it shows no signs of abating. In fact, it’s likely that things will escalate even further when the results of the BMA ballot on industrial action is announced next week — junior doctors seem certain to vote to strike.

This would be an incredibly high-risk strategy for the medical profession and has the potential to be hugely self-sabotaging. At the moment, junior doctors have tremendous public support. But it could take only one needless, tragic death while they were on strike for the support they currently enjoy to crumble. Given the nature of the work doctors do, this is a very plausible outcome. No matter that a skeleton service would continue, with cover by consultants; the sheer number of junior doctors and their vital role in keeping the NHS afloat would inevitably mean that patients will suffer.

There is not a single junior doctor who wants to strike if there is another way out of this mess, and certainly none of them want to cause any harm to their patients. But they feel desperate. They are having ludicrous terms enforced that no worker would tolerate. Hunt’s much-publicised offer of a ‘pay rise’ of 11 per cent was in fact a masterclass in political spin and manipulation. People in the public sector — except, of course, MPs — don’t usually get increases of that sort.

It sounded too good to be true and it was. The offer was entirely disingenuous. It was pure genius because it subtly made it appear that the current row with junior doctors is about a pay rise, which it is not, and also that he had made a generous offer, which he has not. Even the way it was announced — through the press rather than official channels — meant that he got all the headlines while the BMA were frantically on the phone the next morning asking the Department of Health for details.

In truth, the dispute with the junior doctors was never about them asking for more money — it was started when Hunt tried to introduce contracts that would mean pay cuts. All the 11 per cent offer actually does is increase basic pay — when in reality most doctors’ salaries are substantially reliant on additional money from out-of-hours work, which will be cut. In real terms, this means a reduction in their income — a reduction which some estimate at about 26 per cent.

It’s not just about the money. Medics have raised significant concerns about the safety of the new contract, arguing that it would remove the financial penalties that stop hospitals from making doctors work excessive hours, and would reduce training opportunities.

Why on earth is Hunt doing all this? Some doctors have tried to paint him as a pantomime villain causing mayhem for the fun of it, but he is actually quite a decent man. While I might not always agree with him from the ideological perspective of how best to help the NHS, it’s hard to disagree with many of the things he says about it, and he seems to really care.

He is, though, a Gove-worshipper who wants to be blooded. He wants to do with health what Michael Gove did with schools. He wants to be seen as a strong statesman who has taken on something few would attempt and succeeded. Emboldened by the Tories’ new majority, he thinks now is the perfect time for that fight.

He may well have noble sentiments, but he has not thought this through and he has picked entirely the wrong battle. By tackling junior doctors, he has taken on one of the parts of the NHS that works quite well and which delivers amazing value for money. From the point of view of the clinicians, the fact that the Health Secretary fails to appreciate this is emblematic of how out of touch politicians are when it comes to the NHS. And what’s more, the goal he’s fighting for is misconceived.

The origins of the current problems over junior doctors’ contracts can be traced back to the government’s election pledge of introducing a seven-day-a-week NHS. When they first announced this proposal, many questioned where the money to do it would come from, and the government was unable to provide any answers. It seemed particularly strange given that not only was there no extra money in the NHS pot, but we have been constantly told that the NHS needs to make savings — to the tune of £30 billion over the next five years. It just didn’t make sense.

The answer they have stumbled on is to change the contract for junior doctors so that there is less distinction between weekdays and weekends, and to widen the definition of ‘normal’ hours so that doctors can work later without them having to be paid higher rates. Doctors could thus be expected to work Saturdays and late nights for no extra money.

In effect, the plan was to use the same number of doctors and just spread them more thinly over seven days. Unfortunately the proposed changes meant that the vast number of junior doctors who already work weekends or evenings would be significantly out of pocket.

The entire thing is completely avoidable because it’s based on a fundamental misunderstanding of what sort of NHS we really need. The government has been obsessed with a seven-day NHS, but this is a ludicrous pipe dream which they should give up on. They made the same promise five years ago and it failed to materialise, so they are clearly determined that the same won’t happen again. But given the shortage of money, and indeed of doctors, we need to be pragmatic.

The study showing increased weekend hospital mortality that caused so much panic has since been found to be flawed. Even so, of course we must ensure we provide the best care available to those who need it at weekends and out of hours. There is no doubt that consultant-led service improves the quality of patient care. A 2012 report by the Academy of Medical Royal Colleges cited dozens of figures which point to this.

But the government seems to have come up with a wish list of luxuries we simply can’t afford — hence the current fracas with the junior doctors. We need to make the distinction between hospitals opening for safety and opening for convenience.

It would seem far more sensible to look at areas of critical care — A&E, cardiac and stroke wards, maternity services, intensive care; the kinds of places where people are acutely unwell and need regular senior input — and focus our attention there. You’ll find that many of these areas already operate a seven-day NHS as far as the doctors are concerned. Paediatrics, for example, has long ago accepted the need for seven-day-a-week consultant input and have structured services accordingly, without recruiting more consultants.

We also need to accept that some specialities — such as dermatology or rheumatology — do not need to provide seven-day cover. While it might be nice, people simply do not need to have a dermatology outpatient appointment on a Sunday afternoon. Rather than promising the same service every day, we should be prioritising the areas where people are sickest and therefore in most need.

This leads on to the next issue — doctors are not actually the problem with delivering this anyway. Doctors do not operate on their own. In a hospital, they are part of a much bigger system and reliant on many other professionals and services to do their job. It’s no use having a team of doctors seeing patients if there aren’t the services in place that they need in order to do their jobs. You can’t safely discharge older patients unless they’ve been assessed by an occupational therapist, for example.

To run a truly seven-day NHS you’d also need to ensure that there were radiology services, so that people could have scans. You’d need a fully staffed endoscopy suite. You’d need to have fully staffed physiotherapy, speech and language therapy and psychology departments. You’d need full-capacity admin teams to book in appointments, and porters to collect and transfer patients. When you see it like this, the doctors are just a tiny cog in a very large machine.

The government have made a mistake. They did it with the best intentions — they wanted to improve the NHS and improve patient safety. They latched on to the idea of a seven-day NHS without really thinking it through or understanding the issues. They should focus all their attention on ensuring that the critical care aspects of what hospitals do — which is where the sickest patients are — are fully staffed and operating at maximum efficiency. Junior doctors are already working flat out in these areas.

Jeremy Hunt needs to accept that he has made a mistake by pushing a blanket seven-day-a-week NHS agenda, and get back to negotiating a reasonable new contract with the junior doctors that doesn’t mean they will be taking a pay cut.

And the BMA need to be gracious in this, accept his climbdown and reopen the negotiations to ensure that junior doctors get a decent deal and, most importantly, that patients are kept safe.

Max Pemberton is a doctor, columnist for the Daily Mail and the editor of Spectator Health.