Junior doctor contract imposition is flawed on every level

Background

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 contract^{3, 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 pay^{5, 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 hit^5-13, 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 deteriorating^5-13.  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.

Summary

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.

3.            ACAS. http://www.acas.org.uk/index.aspx?articleid=5557. 2015.

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.

15.          CBS. Written evidence to the Public Accounts Committee by Cass Business School. 2016.

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.

18.          NHSP. Evidence submitted to the DDRB by NHS Providers. 2015.

19.          QC RF. The Mid Staffordshire NHS Foundation Trust Public Inquiry. 2013: http://www.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf.

David Cameron's 7 day services 'on the cheap' will cost lives

The government are on the run, the NHS is struggling and they are being exposed as dishonest and incompetent on multiple fronts. The government recently breached the 18 week target for the first time ever and NHS satisfaction ratings are dropping rather rapidly.

A great example of their overt incompetence and dishonesty is the fact that contract reform is 7 day expansion of services on the cheap. It is a scam. DDRB remit set by government made it clear that we are going to be doing more for no extra reward, essentially Cameron's vacuous 7 day plans are being funded by cuts imposed and bullied upon staff.

No matter how you dress this up, this is a scam, amidst widespread recruitment and retention crises, with the consequent dangerous rota gaps increasing, the ONLY safe way to expand services is WITH increased funding.

The NHS' funding is also dangerously low, the 22 billion of 'efficiency savings' are cloud cuckoo - we cannot fund what we have already without huge deficits across the board.

Cameron and Hunt are dishonest, incompetent and dangerous. There is decent evidence that inadequate funding costs lives, in this context the drive for 7 day services on the cheap is not only stupid, it is also overtly unsafe. This is the reality of  #daves7dayscam

Why did David Cameron ignore warnings re #juniorcontract ?

The letter from over 700 individuals which Jeremy Hunt ignores......

Dear Jeremy Hunt,

                                                We are writing this letter as we have serious concerns regarding the DDRB report relating to contract reform which was published on 16^th July 2015¹ which has formed the foundations for many of your proposed NHS reforms.  The DDRB report stated “We find the case for expanded seven-day services in the NHS, in order to address the ‘weekend effect’ on patient outcomes to be compelling”.  This was largely based on evidence presented by NHS England which was unpublished at the time of submission.  Subsequently this work has been published as an ‘analysis’ article, not a ‘research’ piece, in which the authors stated that it was both ‘rash and misleading’ to assume that the weekend effect was avoidable².  This demonstrates the overall significant disconnect between the way in which the DDRB report has interpreted this evidence and the way it has been presented in the British Medical Journal. 

The following concerns we ask you to respond to specifically are detailed below:

1.                   The oral evidence submitted to the DDRB is not published and both the DDRB and Department of Health are resisting attempts at making this available to the public.  If this evidence demonstrates that service reform is in the best interests of patients, then why do you not make this process fully transparent?

2.                   The mortality data was mentioned by you in a speech on the 16^th July 2015 despite the fact that the DDRB report was only published on this day.  The Department of Health are currently resisting attempts to reveal who first made you aware of this data and when.  When did you first become aware of the mortality data that was later published in the BMJ and how did this occur?  Would you care to publish the documentation relating to this matter?

3.                   The authors of the BMJ study declared no competing interests.  The Department of Health are currently resisting attempts to reveal your discussion of this study with other individuals including those from government and NHS England.  Who did you discuss the mortality data with and when?  Would you care to publish the documentation relating to these discussions?

4.                   You attended several meetings with various editorial teams over the course of 2014 including those from newspapers such as the Sun, Sunday Mail and Telegraph.  It has been stated by the Department of Health that these meetings are not minuted and that the full attendees are not even recorded.  Have you discussed the mortality data with the media in these meetings and if so, was this done before the DDRB report was published?  Also is it best practice to attend meetings with the media and not document even a rough summary of what has been discussed?

5.                   The DDRB remit meeting occurred in September 2014 involving Professor Curran and Department of Health representatives including Dr Dan Poulter, while Professor Curran met with Lord Prior on 16^th July 2015 to discuss the DDRB report.  The Department of Health are resisting attempts at making information relating to these meetings available to the public.  Would you care to publish the documentation relating to these meetings?

It is notable that many truly world class 7 day services have already been achieved in the NHS with current contracts, in areas such as cardiology, trauma, stroke and intensive care.  While there is no doubt that service quality can always be improved, it appears that contract reform is not necessary for further improvements.  While it appears that forcing staff to do more antisocial work for no extra reward during widespread recruitment and retention crises is only going to make further service improvements totally unachievable and create more potentially dangerous rota gaps.

David Cameron has spoken on numerous occasions on the power of transparency to raise standards³, while you have made clear that transparency is vital in creating a ‘world class’ NHS⁴.  The significance of these concerns is that should they remain unaddressed it both demonstrates that there is a severe disconnect between your talk on transparency and your actions in government, and that your raft of NHS reforms is based upon a process whose key nuts and bolts remain hidden from public view,

Yours expectantly, 

Words of a not so junior doctor

Sadly despite our common goal of improving NHS care, talks between our union, the BMA, and government broke down many months ago due for reasons which have yet to become fully clear.  Recently the overtly hostile and aggressive mode of the government’s ongoing threat of unilateral contract imposition upon junior doctors has been particularly morale sapping and depressing to endure.  After all, I am rightly expected to be totally honest with my patients, so how can it be fair or right that the government and Jeremy Hunt treat me and my colleagues with such a total lack of dignity and respect?  The details of the contract are complex but the key flaws within the government’s argument can be summarised fairly succinctly.

Jeremy Hunt and the government claim contract reform is essential to create a ‘truly 7 day NHS’.  There are two critical problems with this as what is meant by a ‘truly 7 day NHS’ has yet to be defined, while many NHS services have already been reformed to become high quality fully 7 day services and this has been done within current contracts and well before Mr Hunt’s reign began.  Notably this has only been managed because ground breaking reforms in areas such as cardiology and trauma were clinically driven and the views of those who would have to deliver these very reforms on the frontline were honestly sought.  Therefore the government’s argument is a weak straw man; existing contracts are perfectly compatible with improving services, while pretending to reinvent the wheel of ‘7 day services’ does not magically create a new wheel.

If Jeremy Hunt and government wanted to incentivise better care at weekends, then surely the new contract to achieve this aim would have to increase the reward for antisocial working?  One would think so, which makes it particularly strange that the new contract imposition rewards antisocial hours less than the current deal.  This is particularly problematic in terms of the recruitment and retention of doctors, which are already in pretty dire straits in several areas including General Practice, A&E, Paediatrics and Psychiatry.  Jeremy Hunt’s ‘11% pay rise’ is a disingenuous sleight of hand, the deckchairs have simply been rearranged, the overall pay package is unchanged, money has simply been moved away from rewarding antisocial hours and into the basic pay pot.  Given that recruitment and retention is particularly dire in many of the specialties with a lot of antisocial hours, this makes the contract particularly regressive and potentially unsafe in terms of creating more dangerous gaps in rotas. 

Jeremy Hunt has claimed that junior doctors will work fewer hours under the new contract but has actually removed the only robust contractual safeguard against excessive hours from the contract, the financial penalties for employers who breached hour limits.  At the same time he has introduced nothing credible with teeth which could possibly ensure that his vision could become a reality.  Many of us already work many extra overtime hours which are currently unpaid by the current system, despite Hunt’s ignorantly offensive claims that doctors lack ‘professionalism and a sense of vocation’, the system is still very reliant on this professional goodwill.  Again Hunt’s claims do not fit with the objective reality of the new contract, there will be no more doctors, and with the removal of our only robust hours safeguard, it is highly likely that junior doctors will be left unprotected from dangerous excessive hours.  This inevitably means that patients will be needlessly put at risk of harm; as there is a plethora of solid evidence showing that tired doctors make considerably more mistakes. 

There are many more significant flaws in Hunt’s contract including the negative effect on both research and gender equality, but the recurring themes remain the same: there is a gaping chasm between the government’s rhetoric and the likely reality of the contract they aggressively threaten to impose.  It is no coincidence that both representatives of the Department of Health and Jeremy Hunt routinely refuse to appear in public or in front of the media to take open questions on this mismanaged dog’s dinner, while junior doctors are more than happy to be questioned live and to speak to members of the public on the street to inform them of the reality of this toxic contract imposition.  If the government had such a great progressive contract on the table, why do they hide from public discussion and why have 98% of highly educated professionals voted in favour of industrial action?  The stressful dilemma facing us now is that none of us want to strike, what we want is a safe contract which is compatible with a sustainable 7 day NHS.  However the government has not given us a good option, we have the option of industrial action or a regressive dangerous contract which will destroy any hope of a safe sustainable 7 day NHS in the longer term.  With heavy hearts we have opted for the least bad option of industrial action, knowing not where it will lead, but at least knowing we are doing the right thing for what we hope will be our many future patients in the NHS.  We want negotiation but we welcome the recent move from Jeremy Hunt to engage in conciliatory talks with the BMA via ACAS, however while the government refuses to withdraw its threat of contract imposition meaningful negotiation cannot happen and a strike remains inevitable.

I am honestly not sure what I am meant to feel anymore, the emotional rollercoaster has still to run its course.  Since I graduated from medical school over ten years ago life has certainly had its up and downs, the biggest ups were getting married and having a wonderful daughter, the downs have included failing several exams along the way and the incessant shifting of the goal posts in medical training.  On the whole medicine has been a wonderful career, being a doctor is a great privilege in ways I had not imagined before embarking upon this journey; simply being in a position to meet and learn from so many fascinating diverse characters is a great privilege.  It says a lot given how rewarding I find the day to day job, that I doubt that I would encourage my daughter into medicine these days.  It is a pretty sad indictment on the mismanagement of this situation by the government and Jeremy Hunt that they are bullying through the creation of an environment in which I would not want to see my own child work, consequently they are sculpting an NHS in which I would not want to be a patient, and that is the most damning indictment of them all.  The continued creation of a high quality 7 day NHS can only be done with collaborative and cooperative working, bullying misguided flawed policy from on high will only create more problems, not solve them.

Dear Mail Group.......

Dear Mail Group

I am writing for several reasons, all under the same general umbrella of admiration for your mighty journalistic tradition which invariably serves the public interest above all else.  It is most excellent that you are now taking such an interest in the junior doctor contract story, particularly the way in which you are now focusing on the characters involved, it is most educational and intellectually invigorating.    Obviously the fact that doctors are in uproar about the lack of robust safeguards to protect their patients from doctors working dangerous excessive hours is not really important.  Also the fact that antisocial hours are going to be less rewarded during a global recruitment and retention crisis is also immaterial, the inevitable workforce crisis that will result will not matter.  It is far more noteworthy to Mail readers that some junior doctors are also young photographic entrepreneurs and have healthy interests outside of medicine, does this make them capable of membership of David Cameron’s ‘party of the workers’?  Or is membership of this neat little club contingent on only particular types of work such as running a hedge fund or banking?

The fact that we already have excellent 7 day services in many areas with the current doctor contracts is also irrelevant, we should simply trust Jeremy Hunt when he says contract reform is necessary for improving the quality of care, he is a man with an impeccable record, a man without conflicts of interest, a virtuous beacon of noble text messaging just at the right Murdoch moment.  This honourable Health Secretary would never attend non minuted meetings during taxpayer funded working time with newspaper editors such as Geordie Grieg of the Mail on Sunday in June 2014 and  then refuse to release any details of what was discussed, would he?  That pesky Freedom of Information does need scrapping while we’re on that topic, allowing the public to understand the real motives lurking behind the big decisions would not really help propagate the benevolent interests of the Daily Mail owners would it?   Meanwhile it is quite right that the Mail ignores the ‘Hunt effect’ which demonstrates that the Health Secretary’s scaremongering may be costing patients their lives; it is also quite irrelevant that Hunt has been instrumental in burying the most important lesson from the Midstaffs disaster, that being the vital  safe staffing work by NICE.

 Anyway I digress, I am just so grateful to you for your powerful investigative journalism, it really is a battle against all the odds, David against Goliath: months of painstaking fieldwork lurking on ‘secret’ forums populated by thousands of people which effectively makes them open, covertly watching and waiting, and then striking out, in brazen tones, and motivated above all else by what you think is right, right for you, for your Editor, for your owner, and right for the short term needs of your newspaper.  While we’re on that topic, it’s worth remembering the benevolent history of the Mail itself, Lord Rothmere was a friend to so many, not matter their race, religion or creed, Hitler and Mussolini were certainly not left out of his fold, what a terrible shame that the rest of the British press did not give fascism the support it so deserved.  It is also notable that the working class ownership of the Mail continues with the controlling shareholder of the Mail Group the 4^th Viscount Rothmere is worth around a billion pounds and is a keen supporter of David Cameron.  It is also notable that the noble Viscount, when not fighting for the poor, has non-domicile tax status and pays very little tax on his income, investments or wealth. 

Back to the topic in hand, the Mail really is spot on with its excellently researched article so appropriately entitled “Junior medics’ attempt to plunge the NHS into crisis”.  It really is about time that these lazy workshy junior doctors took their fair share of the blame for the crisis that the NHS finds itself in today.  If only these arrogant spoilt medics, who dare own homes and spend weekends doing things other than working, had implemented the Conservative party’s magnificent Health and Social Care Act better, then we would be not be in the mess we’re in today.  Surely funding shouldn’t matter and the real terms reduction in funding that frontline services have experienced should really be no excuse, these lazy wasters should be working for free and donating their personal possessions to the cause to make up for the government’s rank incompetence.  By fighting against Jeremy Hunt’s magnificently progressive new contract, which promises to make everything better because he says it will, they are the ones to blame for any resulting crisis.  They should just accept this great new deal, after all who needs safeguards from dangerous excessive hours, who needs to retain and recruit staff when there are numerous huge gaping chasms in rotas already, who needs to value staff and reward them fairly for working more antisocial hours? 

The fact that the workable details of the contract have yet to be revealed despite Hunt threatening to impose it in well under a year is a trivial minor snag, these whingeing junior medics should get on with it, sell their kidneys and just damn well do what is in the greater good of the Conservative party.  7 day working according to Hunt will be magnificent, staff recruitment in Australasia is going well, social care is in crisis, spreading everything thinner over 7 days will have obvious gains, the inevitable staffing crisis will be used as a convenient excuse to centralise emergency services, shut lots of smaller hospitals that only the public want, and then it will be child’s play to sell off a lot of profitable elective services to the private sector vultures who are already lurking in the shadows.  This is democracy; this is progress, for the small minority of super wealthy people like our esteemed Viscount it is.

Finally one last thank you, I am so very grateful for your finely engineered prose who so succinctly details the real problems with the junior doctor contract situation.  If only the country was governed by the Daily Mail, what a place it would be, we could get rid of these workshy lazy maggot-like junior medics, we could dump them on Australasia as the convicts of old, and if we are to believe the honourable Mr Hunt, they could simply be replaced with various health ‘Apps’, after all technology is the way forward, long live the Viscount and the party of the 'workers'!

With love

A junior doctor

Letter for Jeremy Hunt via HEE

Dear Health Education England

I am writing in response to the message sent by Jeremy Hunt, the Secretary of State for Health, which was sent out to all junior doctors by you on the 4/11/2015.  It is most excellent that there is now a direct channel of communication between junior doctors and Mr Hunt.  As you now appear to be acting as his intermediary, I would be very grateful if this could be forwarded straight back to Mr Hunt,

Thanks

Ben Dean

Dear Mr Hunt

It is most kind of you to have spent the time to write a letter to junior doctors and send it to us via Health Education England (HEE).  I know you are a very busy man and that it must be hard to find time to keep up to date on what junior doctors do and our contract situation, especially given you have so many non minuted meetings during taxpayer funded time with editors from newspapers such as the Sun, Mail, Times and Telegraph.  I also know you are very busy keeping up to date with the latest research from NHS England.  It was also much appreciated that your message reached us via the media well before the email from HEE, I presume this was just to make sure the message got through, it was so very thoughtful indeed.  Anyway onto a few simple points I would like to make regarding the junior contract situation, I presume they were all innocent errors, after all you do have so much on your plate.

Firstly on safety, I would love to know a little bit more about the details of how junior doctors will be protected from excessive dangerous hours by CQC inspections.  The removal of the current system of hours monitoring which is a robust independently overseen process with real teeth and its replacement with a system which appears utterly toothless appears nothing other than dangerous.  The assumption that the CQC will manage to enforce safe hours with a 40% cut in funding, without the necessary expertise and without proper independence from government, appears nothing other than cloud cuckoo delusion which will catalyse the acceptance of dangerous working practices.

Secondly on the ‘pay rise’, the way in which this has been released and propagated in the media is nothing other than a disingenuous insult.  It is worth remarking that junior doctors are not paid for overtime, our routine rota’ed hours are covered by basic pay and banding supplements.  Certainly this is an unusual system but it works pretty well, but it does mean that effectively our basic pay for routine hours worked consists of both our basic pay and our banding payments combined.  In reality our pay is at best being frozen, and in three years’ time when the sticky plaster pay protection ends, many of us will experience significant pay cuts.  Therefore please stop misleading the public by pretending that a rise in ‘basic pay’ represents a pay rise, it clearly does not.

Thirdly on your 7 day reforms, it should be noted that many services are already high quality and 7 day, and this has been achieved effectively using current contracts for both junior doctors and consultants.  The way in which you pretend contract reform is necessary for improving the quality of patient care is both deceptive and dishonest.  Given the recruitment and retention crises we are experienced in many areas of medicine today, forcing more antisocial hours of no extra reward is likely to worsen this already brittle situation, thus posing a serious threat to patient safety.  This ignorant ‘Gatling gun’ approach to service reform is unsupported by a credible evidence base and likely to be highly counter-productive, both in terms of financial sustainability and in terms of patient safety.

Fourthly on the argument that transparency can drive better systems for patients, one you have used rather selectively in various speeches in recent months.  I am a strong proponent for openness and transparency; however one has to be consistent in applying this logic.  You have frequently exploited the Midstaffs scandal for your own political gain, but sadly the most important lesson from this mess looks like being ignored.  The NICE safe staffing work has been buried under your watch as a result of political expediency; this is a travesty for those who have suffered poor care in the NHS.  This is not the only example of your cherry picking when it comes to transparency, your refusal to release details of what you discuss with editors from newspapers such as the Sun, Mail, Times and Telegraph is another classic one.

I would so much appreciate if you had time to respond to the specific of these concerns raised, whether you choose to answer these via HEE, the media or directly to myself, I would appreciate some honest answers whatever the mode of delivery.  Certainly given how frequently you meet with the media behind closed doors, it may be easiest to get your response out as a Sun or Times editorial, I’m sure I would be able to notice it was you responding, even if you were not named directly.  I do realise you are a very busy man, I know you have a copy of Trisha Greenhalgh’s excellent book on evidence based medicine to read, as well as a letter from the BMJ editor Fiona Godlee to respond to, you also have meetings with the Colleges to attend to, as well as liaising with NHS England about their research agenda.  Thanks so much for your time, I do hope you don’t have to resort to hiding behind vegetation this time around,

Yours

Ben Dean

DH miss the point and fail to apologise for breach of confidentiality

This is the full response I have received from the DH:

"Our ref: DE00000948527 

 

Dear Mr Dean,
 
Thank you for your recent correspondence to the Department of Health about the image used in a tweet posted on 17 July.  I have been asked to reply.

The Department has looked carefully at this matter and what took place was an entirely unintentional mistake.  The Secretary of State for Health’s sole intention was to celebrate some excellent clinical work he was grateful to have been able to see first-hand at University College London Hospital.

As soon as the Department was alerted to the mistake, the image was removed and replaced.
 
I hope this reply is helpful.

Yours sincerely,
 
Paul Larkin
Ministerial Correspondence and Public Enquiries
Department of Health"

 

The DH totally fail to see the point of the complaint.  It is utterly irrelevant that the clear error was 'unintentional'.  Jeremy Hunt clearly breached patient confidentiality with his tweet and there has been zero consequence to this action.  We have not even seen the whiff of an apology.  Given Hunt's talk of candour and the way in which frontline staff are regularly punished for such clear breaches, it is utterly limp of the DH to write off such a breach in this manner.  It really says a lot about their incompetence and their failure to live by the rules which they are happy to destroy others with.

Jeremy Hunt tweets photo with in-patient names clearly visible

 

Jeremy Hunt is not having a great day and my heart bleeds.  Having attacked and denigrated NHS staff as he continues his campaign of destroying the NHS as a publicly delivered service, poor Jeremy made the error of tweeting a photo of himself posing within a hospital ward with hospital staff.

Unfortunately for Jeremy he tweeted this photo and contained within was a board listing all the patients on that particular ward.  The patient names were clearly visible.  If a doctor did such a thing, they could expect definite consequences.  As things stand the tweet stayed up for a good few hours, then was replaced by a new tweet with the patient board fuzzed through.  There has been no apology or admission of this confidentiality breach as yet.

I would urge everyone to write to the Department of Health via their online complaints form below.  At the very least Jeremy Hunt should apologise for his tweet and apologise to all those whose names were clearly visible in the original photo.  He is a senior public official and should know far better, after all isn't candour something he feels strongly about?

 

http://www.info.doh.gov.uk/contactus.nsf/memo?openform

 

"Dear DH

 

I would like to make a formal complaint about Jeremy Hunt's tweet on the 17/07/2015 (see attached screen grab).

 

The photo shows patient identifiable information clearly on a board in the top left of the photo.

This tweet constitutes a clear breach of the Data Protection Act.

 

I expect this matter to be thoroughly investigated and at an absolute minimum Jeremy Hunt should issue a full and frank apology to the patients whose confidentiality he has clearly breached,

 

regards"

GMC consultations - please respond!

Here is my response to the GMC consultations on 'credentialing' and 'generic professional capabilites':

 

"Dear GMC

As regards the two consultations:

Firstly as regards credentialing, the whole premise behind your goals is flawed.  There is no proven benefit to introducing credentialing.  It simply cannot be assumed that introducing credentialing will enhance regulation and protect patients.  Rather the opposite is more likely, credentialing is likely to result in more expensive box ticking paperwork which will distract clinicians from protecting patients and will provide no tangible gains to patients.  The benefits to credentialing should be proven before an expensive and possibly harmful bureaucracy is forced upon doctors against their will.

Secondly as regards the 'generic professional capabilities', the whole premise behind this plan is deeply flawed.  Doctors in training are already overwhelmed by a burdensome bureaucratic system that consists of largely unreliable and poorly validated assessments.  The harm done by such a flawed competency based framework are clear and well documented in the medical literature.  While the framework domains adds nothing to what is assessed by the extensive array of assessments that doctors in training are already subjected to today.  The GMC has simply not provided a clear rationale as to why such a framework is necessary.  Without a proven need the framework promises to introduce yet more burdensome bureaucracy on doctors in training at a time when service pressures are becoming increasingly unsustainable.  While the talk of assessments will simply lead to more box ticking of more poorly validated assessments which will do nothing to help standards or patients, rather the opposite.

I would therefore like to register my general lack of faith in both these consultations as the need for these proposals has not been adequately demonstrated,

First the GMC should do no harm,

regards"

 

 

I would urge all doctors to email your thoughts to educationconsultation@gmc-uk.org - do not feel obliged to use the GMC's highly constrained white space forms, simply express your opinion to them without being pidgeon holed.

GMC spend on media relations

"The GMC Media Team

 

The Media Team work with colleagues across the organisation to promote the work of the GMC; and they have direct relationships with a variety of journalists, from both national organisations and specialist publications.

 

There are 4 different roles within this team and the staff resources have been allocated as follows:

 

·         Head of Media Relations (London Level 2) – £60,444 – £92,530
·         Media Relations Manager (London Level 3) – £39,766 - £58,338
·         Media Relations Officer (2 officers in Manchester Level 4) - £23,413 - £34,090
·         Media Relations Officer (2 full time, 1 part time officers in London Level 4) – £29,078 - £42,546
·         Communications Executive (London Level 5) – £25,582 - £37,337"

This appears to me to be quite a lot of money and funded by doctors.  Certainly this is a discussion that should be had in the public arena.

Niall Dickson's response.....:)

"The independent Shape of Training review was established by the four governments of the UK and was supported by a number of organisations including Health Education England, The Medical Schools Council, NHS Education Scotland and The Academy of Medical Royal Colleges.

It was the GMC’s role as the secretariat to arrange meetings with a whole range of organisations to enable them to discuss the proposals. However, it is ridiculous to suggest that there were any so called ‘secret meetings’ held with politicians or anyone else. Of course there were routine meetings to help Professor Greenaway gather views from those with an interest in this area. There was also a public consultation, discussions and country-wide events throughout the process and the details are available for all to see on the Shape of Training review website.

As is perfectly normal the only notes taken were by GMC staff, the purpose of which was to support our secretariat role and as an aide-memoire for the sole use of Professor Greenaway who led the review. It is standard practice for these types of notes not to have been publicly available.

There are differing views among stakeholders as to what changes are required but there is a consensus that more needs to be done to meet the changing needs of patients and to provide high quality care in the future.

The review has made recommendations that could require changes to postgraduate training and everyone accepts that more work needs to be done to understand the benefits and impact of this. However, any proposal for change will involve seeking the views of doctors in training, those who train doctors, and those who fund education, training, and the health services across the UK."

I have reproduced Niall Dickson's response above, just in case it is retracted.  I have to say I found it rather revealing for several reasons.

Firstly Niall Dickson claims it is 'ridiculous' to claim there were any secret meetings, however there is no justification to support this statement.  The meetings which were called 'secret' took place behind closed doors, were not formally minuted, were not referenced in the review's paper trail and were not reflected in the review's evidence section.  To anyone outside the review, the meetings can accurately described as 'secret' in my opinion.

Niall Dickson is also rather economical with the story on the GMC's use of the meeting notes as the GRC judgement made clear.    The talk of 'consensus' is ironic given that the key review recommendation to shorten consultant training went against the majority of the consultation respondents' opinion.

Finally the response from Niall Dickson totally ignores the four questions posed to the GMC about various issues that were unearthed and supported by various pieces of evidence, I wonder why Niall?

Due process, or lack of it, and the Shape of Training

This week the BMJ published my opinion piece on the 'Shape of Training' review:

"The GMC spent more than £4000 on legal fees in resisting my freedom of information request. The court also commented on information obtained from the GMC’s internal correspondence that did not relate to the Shape of Training review: “The evidence was that at one meeting an individual sought an assurance that the minutes would not be published and his willingness to discuss matters freely was contingent upon getting this assurance.” This shows the general way that the GMC effectively allows lobbying on policy off the record, despite supposedly being an independent organisation."

As I have previously described on several occasions, there are numerous problems with the review.  The case and evidence for the major structural change proposed have never been adequately made, the logic underlying the review's recommendations is lacking, the potentially harmful consequences are huge and the methodology is far from transparent and robust.  There is also the broader issue of transparency and the public interest:

"Without transparency there can be no accountability. A reliance on secret discussions may, therefore, erode accountability, potentially leading to policy that better serves the interests of government than those of anyone else. Why key matters relating to patient safety cannot be “fully considered and debated” in a transparent manner before decisions are made is incomprehensible to me."

Anyway what's the point?  Well the review is currently in the process of being implemented, so every little thing that we can all do now can make a difference to the outcome for our training and our patients.  The simple things you can do include writing to your MP, sign my petition on 38 degrees, write to your Royal College or trainee organisation, and spread the petition/BMJ article on the social media or via email.  Please make the effort, every little bit of momentum really does help.....