Hunt lied and the DH continue to hide the truth......

Above is a response from the Department of Health (DH) to my MP, Layla Moran who very kindly sent them a question about pre-conditions to negotiation of the junior doctor contract.  The background to this is complex but this specific issue can be summarised fairly concisely.  Jeremy Hunt has repeatedly stated that there were never any 'pre-conditions' to negotiating the junior doctor contract.

Having pursued the truth using the Freedom of Information Act I have proven that on July 16th 2015 the Department of Health told the BMA that they would not negotiate the junior doctor contract unless the BMA ceded to all 23 recommendations of the DDRB report in full. 

To anyone with the most basic of grasp of the English language it is clear that from July 16th 2015 the DH had therefore put into place a clear set of 'pre-conditions' to negotiation, something that Hunt and others have repeatedly lied to cover up.  Hunt's friends in the media such as Danny 'the Fink' Finkelstein have also spun various incoherent nonsense and tried to paint black as white in perpetuating the dishonest myth that pre-conditions are not pre-conditions.

The above response from the DH sums it all up neatly as it describes events over 2013/14, then it talks of the DDRB remit and report, however the letter then bizarrely then skips forward to September 2015 and totally ignores the critical period of July and August 2015 when the pre-conditions were in place.  It is truly Kafka-esque in it's total failure to even get vaguely close to answering the actual questions regarding pre-conditions to negotiation.  The DH's attempts at Orwellian newspeak have truly plumped new depths of ineptitude.

The NHS 'crisis'

There's no doubt that some of the most used cliches are so widely used for a reason, probably relating to them holding a fair bit of the truth fluid.  I think the cliche along the lines of 'you learn most about yourself when times are tough' is a pretty good one.  Where am I heading with this?  Well I think you can apply it to those within a system in positions of power during times of genuine crisis and one can certainly learn a lot.

It doesn't take a genius to recognise the overt system-wide crisis in the NHS today, it's also most certainly not a sudden isolated event, it's very much an acute on chronic one.  The warning signs have been there over several years, worsening waiting times for elective and emergency care, worsening staff recruitment and retention at many levels of the system (including nursing staff, doctors and allied staff in both primary and secondary care), growing shortages of staffed beds, growing problems in the timely provision of social care and more.  The causes are certainly complex but a few things stand out which include the failure to increase social and health care spending in a manner that can meet the rising demand, and certainly eminently poor and cost ineffective health care policies such as Lansley's HSCA, various expensive PFI deals and various other misguided structural changes to health care delivery.

This takes me onto what we have learnt about those in tangible positions of power such as the Health Secretary, the Prime Minister, various Department of Health and NHS England executives and those in positions of managerial power within NHS Trusts.  Jeremy Hunt has been strangely hidden from public view at times when the harm of the current situation has become all too apparent in terms of patients as a direct result of unacceptable delays in their care at various levels of the system, and when he has been in front of the news cameras his stubborn reliance on cheap misleading propaganda has been a dead giveaway.  Theresa May has fared no better, unable to offer any meaningful long term solutions and simply repeating several tired soundbites in combination with some stubborn and ignorant denial.  Most staggering has been the spin and downright lies emerging from government bodies such as the DH and NHS England.

The denials despite overwhelming evidence of a crisis have been Kafkaesque in their sheer unwillingness to own up to reality.  Although some brave Trusts chiefs have spoken out, the number who have not is rather worrying and in the context of NHS England quite deliberately trying to silence anyone who dares report the reality of the crisis to the media it is an extremely worrying picture in terms of cultural failure.  Despite Hunt's endless rhetoric about safety and eradicating a 'culture of fear', it is quite clear he has presided over a series of disastrous decisions which have led to a deeply unsafe situation and a culture in which staff are even more afraid to speak out about the reality of what patients are experiencing on the front line.  It was telling that journalists were struggling to find junior doctors willing to speak to them anonymously about conditions in the workplace, staff are scared and rightly so, given the malignant and vindictive nature of managers who will exploit current regulatory structures to bury them underground.

In my opinion these recent events have neatly demonstrated exactly where the NHS' problems have come from and I would put a huge portion of the blame at the door of those politicians and managers who prioritise short term objectives such as their careers and a political party over the long term health of the public.  This is most definitely not just a little blip, a busy winter down to a bad flu season, as someone working inside the service I can tell you this is a major tipping point that has taken many years of denial, negligent management and bullying to regress towards.

Any service industry is highly dependent on its workforce and the NHS is no exception, staff are currently at breaking point and this should worry you all, as in the context of the already dire recruitment and retention of pretty much all staff groups in the NHS, this is something that could get a lot lot worse.  The only way for progress is for the management of the NHS to be fully uncoupled from the regressive short term political needs of the current bunch of self interested Charlatans in power.  Only then can the NHS be setup up to best serve the public interest in a way that is focused on the longer term needs of the population over many decades, not the short term political cycle of just a couple of years.  Certainly one has no chance of fixing anything while those in positions of real power have their heads so firmly up their own backsides that they cannot even see reality when it is pounding its fists on their thick skulls.

The dampest squib - Shape of Training outcome

So the Shape of Training Steering Group have published their final report and I think it's fair to say it's a massive improvement on Professor Greenaway's disastrous first draft.  My summary article in the BMJ from 2015 summarises the huge problems with the initial report and the rather dubious political influence upon the review that was taking place off the public record.

The most dangerous and misguided ideas from the initial report have unsurprisingly been shelved, one wonders how much the pressure of certain militant individuals and various representative trainee organisations influenced this rather obvious u-turn.  The moving of full GMC registration has been deemed outside of the review's remit, while the certificate of completion of training (CCT) remains and is not to be replaced with a a certificate of specialty training (CST).  

The only real change is the introduction of post CST 'credentialing' and in reality credentialing is here already in practice, even if not by name.  The devil will be in the detail of how exactly credentialing is defined and setup in the future.  It has the potential to be positive if it can be used as a lever to ensure that post CST training achieves certain outcomes.

Overall the bottom line is that the Shape of Training represents a humungus missed opportunity in terms of assessing the current problems in UK medical training and addressing them.  I would argue that the deep entrenched bias in the way in which the review was conducted involving the hidden political meddling meant this review never objectively analysed the current state of UK training, and as a result it has largely been a total waste of time and money.  The government wanted to dumb down training standards and make training cheaper, so the real quality issues in current training were totally ignored and as a result, the review has suggested little that will make any positive contribution to training quality.

The way in which training is regulated and funded need sensible reform urgently.  It is utterly crazy that some trainees get really substandard training at the expense of being abused as rota fodder by Trusts.  The system needs to be more responsive with homeostatic mechanisms in place which result in poor training posts being canned.  The big elephant in the room here is NHS funding.  In order to improve training quality trainees need to be far more supernumerary in their role, so that they can be free to get the best training exposure and so that they can be pulled instantly if their training needs are not being met.  Sadly as things stand too many poor training posts exist and the system is not responsive enough to eradicate these failures, and the Shape of Training review completely missed the point.

Breathtaking incompetence - a monumental shambles in their hands

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.

The BMJ talks a good talk.....

The BMJ does publish some very insightful work at times, I particularly enjoyed Iona Heath's recent piece on 'conflicts of interest within England's NHS':

"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.

My thoughts on physician associates et al

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 retention^5,6.  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/.

How to be healthy and smoke cigarettes? The HSJ's lack of impartiality revealed

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:

To equate not attending the HSJ's roundtable as 'deciding the treatment of and future working conditions of doctors wasn't important' is not only ludicrous and self important, but it is demonstrative of a recurrent bias shown by the HSJ towards the BMA.  No wonder the BMA didn't want to attend when the chair of the discussion appears to have such an axe to grind.  Also discussing the freedom of Trusts not to impose and the overtly harmful nature of a contract imposition is not 're-fighting' as Shaun Lintern has tweeted, I wonder why he spins such reasonable and potentially constructive discussion as such :

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.

The problem with Jeremy Hunt and his fag packet inscribed reforms

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 sand^3,4, but the government’s overtly dishonest approach to informing the public had been repeatedly exposed^5-7.  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 reforms^8-10.  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.