Tuesday, 18 July 2017
I've been reading Rachel Clarke's book over the last few evenings and this is what has inspired me to ramble on the blog today. The mixture of humanity, sharp analysis and reasoned argument makes Rachel's excellent book absolutely essential for anyone interested in medicine, the NHS or healthcare. The way in which the government have ignored precisely this kind of incisive intelligence sums up why we are in a right mess today.
It's worth going back to square one and analysing just how fast so many situations on the NHS have deteriorated. Generally before the Conservatives took power in 2010, many of the crises which exist today did not exist. The disastrous recruitment situation regarding junior doctors, consultants, nurses, physios, OTs and GPs did not exist pre 2010. The number of small GP practices closing has rocketed since 2010. The social care crisis has been a recent phenomenon in the context of huge real terms funding cuts. The deterioration in AE waits and elective treatment performances have all happened post 2010.
Certainly nothing was perfect pre 2010 and disasters did happen, however it is fair to say that the system wide failure that we see today definitely did not exist in that period before the Conservatives took power in 2010. This is a point which Rachel Clarke makes eloquently in her book, despite all the hot air spewing forth from Jeremy Hunt's orifices, nothing solid has actually been done that has improved the reality of the care on the front line of the NHS. All we have seen from Hunt is smoke, mirrors, propaganda and dangerous arrogance.
Nowhere is this better demonstrated than in junior doctor recruitment and retention. Things were steadily declining from around 2012 onward, then Jeremy Hunt bullied and imposed a contract upon doctors, unsurprisingly things have only got worse as a result. Current recruitment data is dire, almost one in 5 paediatric jobs are unfilled and specialities that were previously massively oversubscribed cannot even fill their training numbers. The ins and outs of the contract debate are complex, Rachel's book portrays a very accurate picture of events. The imposition of a contract remains a great example of Hunt's overt ineptitude and arrogance in one, it can never make sense to force something upon ones employees, particularly when recruitment and retention was in such a dire state in the first place.
There has been too much ineptitude from the likes of Hunt, the Department of Health and their minion NHS England to summarise it all without writing several volumes of dense text. However it remains clear that until we have some candour and apologies from the dictators at the top of this authoritarian shambles then things will only continue to get worse. Fundamentally leadership is about listening and the current leaders at the top of the NHS have their earplugs in. The bottom line is the NHS is crumbling because our political system has failed. You get what you pay for in life and there are no magic solutions, meaning promising the hollow gimmick of '7 day services' without any funding or staffing to enable it can only result in a dismal own goal. Until our leaders are honest about what can be sustained with skeletal funding then we'll continue to see the service crumble and staff flee for greener pastures elsewhere. Rachel Clarke has hit the nail on the head and Jeremy Hunt should be deeply ashamed of himself, alas for that to occur he would have to exhibit a degree of insight, something he has not demonstrated to this day.
Friday, 14 April 2017
"Although definitions and guidance about what to declare are useful, the real challenge facing individual clinicians and employers is to find a way to declare interests in a practical and meaningful way. "
I couldn't agree more and the BMJ has often written some very coherent stuff on conflicts of interest. Therefore one would expect the BMJ to actually apply the same rules to itself and the studies it chooses to publish. Sadly when applying the rules to the Freemantle 2015 study, the BMJ has been found to be sadly lacking.
Since the publication of the Freemantle 2015 study in the BMJ much evidence has emerged. It is now apparent that the commissioning of the study came directly out of NHS England's 7 day service work and involved NHS England's senior leadership including Simon Stevens. The private firm Deloitte were also involved. None of this was declared by the authors, and the evidence demonstrates that Bruce Keogh was fully aware of this situation and the fact that the study had not simply come from just his request, but had involved the senior leadership of NHS England including Simon Stevens. Notably the DH were also intimately involved in this process and kept very well up to date on the 'research' on which Jeremy Hunt later relied, labelling it 'independent'.
The BMJ has still not acted to prevent readers from being misled by the overt failure of the Freemantle authors to adequately declare who actually commissioned the study. The full political context to the study's commissioning is vital in its interpretation. This failure is a clear breach of the BMJ's guidance to authors, this being that of the ICMJE. Whether issuing an adequate erratum or retracting the study, the BMJ should act and their failure to do so smacks of hypocrisy, they frequently hold others to such high standards but when dealing with the Freemantle authors they appear to be ignoring their own rules.
Monday, 13 March 2017
I read the latest edition of JTO with interest and noted the comments from the Editor regarding 'physician associates', as well as the feature by Anandu Nanu. Certainly it is possible that other allied healthcare professionals can be used to provide valuable service and this can potentially improve the training of junior doctors; perhaps medical support workers can be more cost effective and useful in this regard than physician associates, as much potential junior doctor training time is wasted doing many lowly skilled bureaucratic tasks.
The significant underlying barriers to improving training remain unaddressed by the introduction of more allied staff however. The fundamental root problems include government enforced austerity, the resultant widespread NHS deficits, huge budget cuts to HEE and an unfunded service expansion being pushed amidst a drive for an utterly unachieved £22bn of 'efficiency savings'1-4. Then combine this government ineptitude with a perfect storm in terms of an unpopular inadequate new junior doctor contract which is only catalysing a marked deterioration in junior doctor recruitment and retention5,6. The overall result is an inevitable deterioration of the quality of surgical training.
Training can only be improved with adequate government investment which may then both address the dire recruitment and retention of staff, as well as increasing staffing levels to absorb the less useful service provision currently performed by junior doctors. In the current financial and political environment, the introduction of more allied health professionals can only be of benefit to training if they are in addition to the current workforce. In the current environment it is far more likely that junior doctors will be replaced, rather than added to by these new staff; and this can potentially harm training further by increasing the burden on the remaining doctors. Fundamentally without adequate funding, training quality is only going one way.
1. CBS. Written evidence to the Public Accounts Committee by Cass Business School. February 18th 2016.
2. PAC. Managing the supply of NHS clinical staff in England. Fortieth Report of Session 2015–16. 27th April 2016 2016.
3. Dunn P MH, Murray R. Deficits in the NHS. The King's Fund. 2016;http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/Deficits_in_the_NHS_Kings_Fund_July_2016_1.pdf.
4. Campbell D. Secret documents reveal official concerns over 'seven-day NHS' plans. Guardian. 2016;https://www.theguardian.com/society/2016/aug/22/secret-documents-reveal-official-concerns-over-seven-day-nhs-plans.
5. Campbell D. Almost half of junior doctors reject NHS career after foundation training. Guardian. 2015;http://www.theguardian.com/society/2015/dec/04/almost-half-of-junior-doctors-left-nhs-after-foundation-training.
6. Dean b. The new junior doctors' contract will create a staffing crisis in the worst possible places. Telegraph. 2016 2016;http://www.telegraph.co.uk/news/2016/04/28/the-new-junior-doctors-contract-will-create-a-staffing-crisis-in/.
Tuesday, 11 October 2016
Much has been said about the HSJ roundtable discussion last week, indeed the HSJ's piece relating to this discussion is due in the next few days. So I hear you asking, why am I asking so many questions and probing the exact context to this roundtable event? Firstly this tweet aroused my suspicions, this was tweeted at the end of last week by the HSJ's editor Alastair McLellan:
It was interesting that the HSJ were so keen to publicise the fact that the BMA did not send a rep to their roundtable event. It is even more interesting when one considers that the HSJ didn't provide a fair or full context to the BMA's decision. I also wonder if any other big organisations were invited and didn't attend, it has subsequently become clear that several major trainee organisations were not invited. Obviously the BMA didn't want to comment directly as it would simply draw attention to an event which they did not want to send a rep to for whatever reason.
Three junior doctors attended the roundtable event as they had every right to do. Despite the somewhat rambling hypocritical hyperbole from some quarters, it really doesn't help to make this personal, so sorry to disappoint by sticking to the facts. The key to this whole affair remains the HSJ's conduct and the exact terms of their roundtable debate, not the fact that three junior doctors gave their opinions as a roundtable discussion. I found it fascinating that the chair of the debate, the HSJ's Shaun Lintern tweeted:
This delivered the hint that the HSJ, whether consciously or subconsciously, had set things up to hear what it wanted to hear. It seems that the majority view of the profession is not 'constructive', junior doctors should just accept that Trusts are imposing and accept this silently. To his great credit Chris Kane, one of the junior doctors who took part, has very kindly sent me the invite letter, which appears to show more of the same:
Interestingly no one from the HSJ responded to my polite requests for a copy of the invite letter, I can't imagine why. Now go back to the HSJ Editor's tweet in which he states that the roundtable was on the 'junior doctors dispute', given the above terms of the discussion this seems a rather twisted take on events. Alastair McLellan has repeated this misleading 'dispute' line, while his use of the word 'imagine' to describe the specific terms that were contained within a letter that he signed is revealing:
The above invite letter makes it very clear that it imposition/implementation has been taken as 'a priori'. I find it strange that such a debate on the 'dispute' has effectively assumed that Trusts have to impose the contract, as this is simply not the case, as recently made clear in Justice4Health's recent court case.
Trusts are eminently free not to impose the contract, and given the inevitable massive harm of imposing a contract upon a workforce rather than insisting on further negotiation, it appears a rather strange 'a priori' to have assumed. Not only is it strange but it leads to the propagation of the dangerous impression that Trusts have no choice in this matter. Shaun Lintern chaired the roundtable and the lack of neutrality of his comments about the BMA need seeing to be believed:
Hence the title of the blog. It would be a tad suspicious if a tobacco company organised a roundtable discussion on the best and most healthy way to smoke a cigarette, in a way that did not allow for a discussion as to whether smoking was really an effective or sensible strategy in the first place. The HSJ's terms ("how can one maintain good workforce relations" while imposing a contract) meant the discussion was a bit like asking how can one stay healthy while smoking cigarettes, not a particularly sensible question and we all know what one gets if one asks a silly question. Not to forget the fact that the HSJ seems to have assumed that Trusts have 'good workforce relations' with junior doctors, something I think has become increasingly obviously not to be the case in recent months given the numerous calls from independent bodies for a review. The talk of 'healing wounds' while accepting the harmful imposition as 'a priori' is at best misguided.
Therefore in conclusion, I'll leave you to ponder the HSJ's actions: the spin of of a discussion of how to impose as one about the 'dispute', the selection of those based on who the HSJ felt would be 'constructive' and the terms of debate which took the most effective strategy for Trusts off the table of discussion. The eventual HSJ needs to be judged in this appropriate context. Imposition doesn't make any sense for employers, it can only harm workforce relations overall and this is why I am rather frustrated at the somewhat stilted approach. It soon becomes pretty obvious why the BMA didn't attend and the way in which this was publicised by the HSJ Editor only confirms that this approach was likely to have been correct.
It looks to me as if junior doctors are united in one key way, we all see imposition is the worst option for everyone including our patients and there remains no coherent argument against this sad fact. If we are going to be 'constructive' then the most constructive thing to do would be to continue to emphasise that Trusts are entirely free not to impose, and it is in all our interests to first, do no harm. Imposition can only mean overall net harm and taking this option off the discussion table isn't 'constructive', it smacks more of a head in the sand and deep denial. The harm of imposition will take generations to undo, mark my words.
Wednesday, 5 October 2016
First to set the scene, after years of failed negotiation the government has encouraged NHS Trusts to impose a new contract of employment upon junior doctors despite it being rejected by a majority of 58% in a recent contract referendum. Much in the same way that clinical errors often require a catalogue of failures from multiple individuals, this junior doctor contract dog’s dinner has been created by a multitude of errors and mistakes by many individuals and organisations. One key factor has been the endlessly aggressive, dishonest and frankly disruptive approach of SoS for Health Jeremy Hunt towards the NHS and its staff in general throughout this whole sorry affair1. In a deluded rush to implement his and his government’s disastrously flawed ‘7 day NHS reforms’, the Department of Health’s briefing documents have proven that Hunt and the government have prioritised political expediency over genuine negotiation2:
“Returning to negotiation would delay further contract change and delay implementing this element of your strategy for implementing 7 Day services policy.”
There we have it. Not only had it already been shown that the 7 day reforms were based on foundations of sand3,4, but the government’s overtly dishonest approach to informing the public had been repeatedly exposed5-7. Numerous respected independent bodies have exposed the fact that the NHS has not been provided with the necessary funds and resources with which to implement such reforms8-10. Recent leaks from within the Department of Health have demonstrated that the government knows that the NHS has too little funding and too few staff in order to safely implement these 7 day reforms11. These documents also detailed 13 major risks attached to the reforms including ‘workforce overload’.
Essentially Hunt and this inept government are prioritising a flawed political manifesto gimmick over the lives of patients; the claims that these 7 day reforms are going to improve care are at best vacuous nonsense. In the context of an NHS which is already struggling to safely staff both doctor and nurse rotas12, the bullying of a service expansion without the necessary funds and resources is overtly reckless. Anyway let’s go back to the contract, the recent offer from the government was much improved but frankly that wasn’t very hard given the frankly derisory initial offer from Dalton in January of this year. The vote by junior doctors was somewhat split with 42% accepting and 58% rejecting, however let me explain why the vote is utterly irrelevant to the justifiability of the current contract ‘imposition’.
The question that is of real meaning to junior doctors is ‘Does the new contract address the flaws in the current contract and significantly improve upon them?’; I reckon the vast majority of doctors who voted ‘Yes’ to the contract would agree with me and say that the current contract does not come close to addressing the flaws in the current contract. Doctors are united in the fact that the new deal should not be imposed and that it does not adequately address the current contract’s key flaws. The current offer isn’t terrible but that’s just not of relevance, the government’s arguments for rushing a contract which has been rejected by a majority of doctors are totally and fatally flawed. The perception of a contract is incredibly important, the way the workforce feels treated by its employer is key and in the context of the recruitment/retention crises this contract imposition is going to do incredible damage to an already brittle situation. Notably the Welsh and Scottish governments have opted for common sense and to continue with the current contract until a negotiated solution can be agreed upon.
The bottom line remains that rushing the reform of a contract which is eminently decent is incredibly counterproductive. A huge 94% majority of NHS Providers stated that the current junior doctor contract was not a major block to the 7 day reforms, the need for rushed reform has just never been adequately demonstrated13. The rushed and botched new contract doesn’t address the fact that those working the most brutal and unsocial hours are not fairly rewarded, if anything it may make this situation slightly worse. The current contract is not massively safer that the new imposed contract, but in the current context of short staffing and underfunding both contracts are not fit for purpose. A responsible government’s attitude would be of first, do no harm; the urgent need for change has never been shown, the new contract doesn’t address some very real flaws in the current deal, so first, do no harm. The damage done by imposing a contract which has been rejected by a majority of doctors promises to do untold harm which may take generations to undo.
The one positive in this whole shambolic affair is that at least the public can see Jeremy Hunt and this government for what they really are. The evidence is now out there, the NHS is in overt crisis, this government’s underfunding and their disastrous treatment of staff have seen all key performance metrics significantly deteriorate in recent years. Hunt’s claims of improving safety have been shown to be dishonest and misleading; he is presiding over the destruction of a safe sustainable NHS. The prioritisation of a fag packet inscribed political manifesto gimmick over evidence and genuine negotiation, over the morale and wellbeing of staff, is nothing but another filthy stain on this government’s dismal NHS record. The context to this contract imposition is vital, and evidence now shows that this government was never willing to negotiate in genuine terms, they were never willing to assess the safety evidence objectively and as a result they are doing an immense disservice to all of our patients. Shame on Jeremy Hunt and this government, it is time that our NHS ‘leaders’ stood up to remark upon this betrayal of the public interest in the name of deluded political expediency.
1. Hunt J. Speech at the King's Fund. https://www.gov.uk/government/speeches/making-healthcare-more-human-centred-and-not-system-centred. 2015.
2. JusticeforHealth. Skeleton Argument on behalf of Justice for Health LTD vs SOS for Health. 2016.
3. Meacock R, Anselmi L, Kristensen SR, Doran T, Sutton M. Higher mortality rates amongst emergency patients admitted to hospital at weekends reflect a lower probability of admission. Journal of Health Services Research & Policy. 2016.
4. Meacock R, Doran T, Sutton M. What are the Costs and Benefits of Providing Comprehensive Seven-day Services for Emergency Hospital Admissions? Health economics. Aug 2015;24(8):907-912.
5. Dean B. The full political context was not adequately declared. BMJ (Clinical research ed.). 2016;http://www.bmj.com/content/352/bmj.i1762/rr.
6. Sims A. Jeremy Hunt's department knowingly 'airbrushed weekend deaths study', according to email. Independent. 2016;http://www.independent.co.uk/news/uk/politics/jeremy-hunts-department-knowingly-airbrushed-weekend-deaths-study-according-to-email-a7167506.html.
7. Bloch S. Hunt 'misrepresented' data on 7-day NHS. BBC website. 2016;http://www.bbc.co.uk/news/health-35597243.
8. PAC. Managing the supply of NHS clinical staff in England. Fortieth Report of Session 2015–16. 27th April 2016 2016.
9. Dunn P MH, Murray R. Deficits in the NHS. The King's Fund. 2016;http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/Deficits_in_the_NHS_Kings_Fund_July_2016_1.pdf.
10. Hopson C. The gap between funds and delivery is a chasm in the NHS: something has to give. Guardian. 2016;https://www.theguardian.com/commentisfree/2016/sep/10/impossible-for-nhs-to-provide-quality-service-something-has-to-give.
11. Campbell D. Secret documents reveal official concerns over 'seven-day NHS' plans. Guardian. 2016;https://www.theguardian.com/society/2016/aug/22/secret-documents-reveal-official-concerns-over-seven-day-nhs-plans.
12. Dean b. The new junior doctors' contract will create a staffing crisis in the worst possible places. Telegraph. 2016 2016;http://www.telegraph.co.uk/news/2016/04/28/the-new-junior-doctors-contract-will-create-a-staffing-crisis-in/.
13. NHSP. Evidence submitted to the DDRB by NHS Providers. 2015.
Thursday, 9 June 2016
This post may be unpleasant reading for some of you but frankly it needs to be said given the way some of the 'debate' is heading. Firstly I'm not going to spin cheap sound bites and propaganda in order to push your opinion into voting 'Yes' or 'No'. It has been clear throughout all this that we are all big enough and ugly enough to analyse the evidence to make up our own minds.
Secondly be cynical. When all this mess was in its infancy, it was clear that the government's tactic of treating us like idiots by inundating us with NHS Employers' propaganda massively backfired. Whatever our opinion, we should not behave as the government did and sink to cheap superficial sound bites without a coherent underpinning of solid rationale. Also in terms of being 'cynical', if people are telling you how to vote and pushing you with cheap rhetoric, then just look at them and analyse what do they have to gain from saying what they are saying? What are their conflicts of interest, where are they trying to end up? We are all biased, whether subconsciously or consciously or both, and it's vital we analyse argument in the context of who it comes from and their conflicts of interest.
Thirdly be pragmatic. Whichever way you intend to vote, consider the short and long term implications of the action. How will the BMA, NHS Employers, the DoH all be served by certain votes? If you want to vote 'Yes', think practically how this will affect the relationship between us and our Employers, and how this may influence the implementation of a new contract? If you want to vote 'No', then think practically how can this vote lead to an improved contract, how would this be achieved and what would need to be done?
Of course this is all massively complex and there are many unpredictable factors, this is life, this is politics. That's why I wouldn't dream of patronising you by telling you what to do. Still, trust no one, look at what everyone has to gain from doing what they are doing, and think through the practical implications of the way you intend to vote. No contract can ever be perfect, there will always be compromises of sorts. Much in the same way as we treat our patients, there is often no perfect option, all options have their pros and cons. It is therefore pretty clear we cannot trust anyone who pretends one choice has all pros and no cons, this is not life, this is disingenuous spin.
My conflicts of interest: I have no income other than my NHS salary, I am an Orthopaedic ST5 and I want to see the best deal possible for junior doctors and our future patients.
Wednesday, 23 March 2016
The government is currently in the process of unilaterally imposing a contract on the junior doctors of England. The Scottish, Welsh and Northern Irish government have decided it is not in the public interest to do the same. The Review Body on Doctors’ and Dentists’ Renumeration (DDRB) report published in July 2015 forms the backbone for the government’s rationale for contract reform1. This report involves the ‘delivery of healthcare services seven days a week in a financially sustainable way’. Unfortunately for those intending to analyse the rationale behind these ‘7 day reforms’, many key details remain hidden including the precise meaning of ‘7 day services’ and the specifics of the junior doctor contract. This summary attempts to synthesise the available information in an easily digestible manner.
Contradictory cost neutral expansion of services with no more doctors working less hours?
A leaked Department of Health (DH) report recently revealed that the 7 day reforms could not be done without extra funding and more doctors2. Specifically, it calculated nearly £1bn and 6000 extra doctors were required per annum to deliver 7 day services safely; notably this report has still to be published. However the government has repeatedly stated that overall the junior doctor contract is ‘cost neutral’ and that doctors will work ‘fewer hours’ under the new contract3, 4. This information is contradictory, the government has yet explain how services can be expanded with no more doctors and with doctors working less hours; this sum simple does not add up. Salient to this point is the fact that the funding stream to HEE for doctors in training is being decreased in real terms and when combined with the new contract’s increase in basic pay5, 6, this means that the government has to be cutting junior doctor numbers in forthcoming years, again this is utterly incompatible with delivering a service expansion safely2.
New contract creates new problems and current contract’s main issues remain unaddressed
The new contract is being delivered within a pay neutral envelope1. A widely acknowledged problem with the current contract is that unsocial hours are not always adequately or fairly rewarded. However, the rise in basic pay means that the groups to gain the most from the new deal are those doing zero unsocial hours and zero weekends. The perversity of a pay rise for those without unsocial hours means that on average less money will be available to reward those working unsocial hours. In the context of overall pay neutrality, this means that once pay protection is gone those working unsocial hours will on average have their pay cut. This will exacerbate the recruitment and retention crises in the specialities which are already the hardest hit5-13, making it impossible to deliver 7 day services in a safe or sustainable manner.
Safety is likely to be compromised by this unfunded expansion and watering down of safeguards
Evidence demonstrates a clear increase in mortality as funding is decreased14. The extent of rota gaps within current junior doctor rotas is highly worrying and appears to be deteriorating5-13. Recruitment and retention crises are already rife, particularly in the specialities with the most unsocial hours. The new contract removes the truly independent system of hours monitoring and replaces it with a weaker, less independent ‘Guardian’ based system which is far more open to abuse by employers. Not only are the financial penalties paid to trainees smaller, but the Guardians are direct employees of the Trust and part of the financial penalty for overworking junior doctors will be paid by the Trust to the Trust itself. The impact of deteriorating recruitment and retention upon rota gaps in combination with less robust hours safeguards poses considerable safety risks to patients by the mechanisms outlined by the Cass Business School’s recent submission of evidence to the Public Accounts Committee (PAC)15.
Un-costed, cost ineffective and unnecessary, as well as totally unassessed for both risk and impact
The Director General of the DH recently admitted to the PAC that no formal costings have been carried out for the government’s 7 day reforms16. Recent research has demonstrated that the 7 day reforms are not cost effective17. Over 90% of NHS Trusts stated the current junior doctor contract was not a major block to 7 day working18. The Department of Health has also recently admitted that the junior doctor contract has neither been assessed for risk not impact. This is despite the Francis report making it clear that any major health reform should be both risk and impact assessed, and that these assessments should be debated in the public domain prior to considering implementation of such reforms19.
Overall the junior doctor contract is undermined by the fundamental fact that services cannot be safely expanded at weekends without adequate funding and increased staff numbers. The government’s 7 day reforms remain undefined, they have not been costed, they have not been impact or risk assessed, and they represent a cost ineffective waste of tax payer’s funds which pose a very serious and real threat to patient safety. Not only will this poorly designed contract exacerbate the widespread recruitment and retention crises in the NHS, leading to more unsafe rota gaps, but this bullying imposition will drive morale rock bottom, and this alone will have catastrophic consequences for our hopes of improving services in safe and sustainable manner.
1. DDRB. Contract reform for consultants and doctors and dentists in training – supporting healthcare services seven days a week. Office of Manpower Economics 2015.
2. Elgot JaC, D. http://www.theguardian.com/society/2016/feb/15/weekend-effect-on-hospital-deaths-not-proven-say-hunts-own-officials. Guardian 2016.
4. NHSEmployers. http://www.nhsemployers.org/your-workforce/need-to-know/junior-doctors-contract/faqs. 2016.
5. BOTA. Position Statement: The Worsening Crisis of Medical Recruitment and Retention in the NHS. http://wwwbotaorguk/position-statement-the-worsening-crisis-of-medical-recruitment-and-retention-in-the-nhs/ 2015.
6. Donnelly L. One in 3 trainee GP posts are empty, amid warnings of crisis shortage. http://wwwtelegraphcouk/news/health/news/11517019/One-in-3-trainee-GP-posts-are-empty-amid-warnings-of-crisis-shortagehtml 2015.
7. RCPCH. Children’s unit closure fears as rota vacancies pose threat to patient safety. http://wwwrcpchacuk/news/children%E2%80%99s-unit-closure-fears-rota-vacancies-pose-threat-patient-safety 2015.
8. Rimmer A. Gaps in trainee rotas cause patient safety problems, say consultants. BMJ Careers 2016; http://careers.bmj.com/careers/advice/Gaps_in_trainee_rotas_cause_patient_safety_problems,_say_consultants.
9. Cooper C. NHS hospitals pushing young medics to brink of 'burnout' by relying on them to work extra hours. Independent 2015; http://www.independent.co.uk/life-style/health-and-families/health-news/nhs-hospitals-pushing-young-medics-to-brink-of-burnout-by-relying-on-them-to-work-extra-hours-10333064.html.
10. RCOG. RCOG statement on new contract proposals for junior doctors. https://wwwrcogorguk/en/news/rcog-statement-on-new-contract-proposals-for-junior-doctors/ 2015.
11. Donnelly L. A third of A&E doctors leaving NHS to work abroad. Telegraph 2015; http://www.telegraph.co.uk/news/health/news/11883559/A-third-of-AandE-doctors-leaving-NHS-to-work-abroad.html.
12. Mukherjee K, Maier M, Wessely S. UK crisis in recruitment into psychiatric training. The Psychiatrist 2013; 37(6): 210-4.
13. Campbell D. Almost half of junior doctors reject NHS career after foundation training. Guardian 2015; http://www.theguardian.com/society/2015/dec/04/almost-half-of-junior-doctors-left-nhs-after-foundation-training.
14. Budhdeo S, Watkins J, Atun R, Williams C, Zeltner T, Maruthappu M. Changes in government spending on healthcare and population mortality in the European union, 1995-2010: a cross-sectional ecological study. Journal of the Royal Society of Medicine 2015; 108(12): 490-8.
16. Bloom D. Top Jeremy Hunt advisor admits he has no idea what 7-day NHS will cost. Mirror 2016; http://www.mirror.co.uk/news/uk-news/top-jeremy-hunt-advisor-admits-7435383.
17. Meacock R, Doran T, Sutton M. What are the Costs and Benefits of Providing Comprehensive Seven-day Services for Emergency Hospital Admissions? Health economics 2015; 24(8): 907-12.
19. QC RF. The Mid Staffordshire NHS Foundation Trust Public Inquiry. 2013: http://www.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf.