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What is the NHS? To those who run it, a vast endeavour employing 1.4m people, consuming one pound in every six of public spending. To a patient the morning after a hip replacement, it’s a cup of tea with two paracetamol tablets and a kind word.
The NHS might be more than the sum of its parts, but that doesn’t mean you can forget those parts, the millions of interactions, great and small, that make up every working day – and that is every day.
As a junior doctor, Aoife Abbey, said recently: ‘The NHS isn’t bigger than me, it is a part of me, and every single person that works for it.’
This helps us reflect on some of the extraordinary events that have taken place in recent months.
If you attack the people who provide the care in the NHS, attack the quality of care they are able to give their patients, attack their motives for providing that care, they feel it personally and respond passionately.
The NHS is fundamentally a set of values. We will not allow these values to be condemned for the sake of political expediency.
The government’s attempt to impose an unsafe and unfair contract on junior doctors was an assault on the safeguards that enable them to practise safely, and on the quality of patient care.
That is why thousands took to the streets in those vehement, inspiring demonstrations around the country.
And yet still there was such a lack of understanding from Whitehall that the health secretary suggested that thousands of highly educated, highly motivated junior doctors were somehow being duped; that if only they read the proposals for themselves, they would come to a different view.
They did read them. Ninety-eight per cent voted for industrial action.
How much easier to blame the BMA than to listen to what doctors around the country were saying.
The BMA always sought to enter talks if the government dropped the threats and preconditions that had made negotiations difficult. The talks hang in the balance over this New Year as we press the government for real understanding of doctors’ strength of feeling.
It is difficult not to view this as part of a wider attack on public service workers, with student nurses in England set to lose their bursaries and instead be forced to take on thousands of pounds of debt, and the wholly unnecessary and punitive treatment of those who represent them, in the Trade Union Bill currently going through parliament.
I’m a consultant, and it was very heartening to see so many of my fellow consultants show their support for junior doctors and their willingness to cover for them during industrial action to ensure the continuation of patient care.
But we should also reflect that the stress and uncertainty faced by our colleagues is not entirely down to what the government seeks to heap upon them.
We are one profession, not just during the current dispute but throughout our working lives, and this means that we extend simple courtesy to our colleagues and help make their working lives more liveable.
It means for example that we involve them in discussions about their leave, rather than just posting a fixed rota on the assumption that we own their lives and if they want any part of them back, they have to ask permission.
Junior doctors work with us, not so they can do the things we don’t want to do, but so that they get the training they need to provide the specialised care which patients need.
Meanwhile, consultants have been negotiating since October on a new contract for England and Northern Ireland. We anticipate putting the government’s proposals before members by the end of January.
Among the issues under discussion has been the safe expansion of services. We have been pressing the government for months to explain how seven-day services will be staffed and funded. So far, it has failed to do so.
To be clear, we are committed to patients receiving the same high standards of acute, urgent and emergency care seven days a week, and there are some excellent examples around the country of clinical leadership of better services.
But the danger in the government’s profound disengagement is not just that the work of expanding services will be dumped, unresourced, on to the shoulders of the NHS, but that the rhetoric will come before the reality of what patients actually want.
In October, an evaluation of the government’s extended access pilots in general practice found ‘very low’ take-up of Sunday appointments. Will the government listen to evidence like this, or will it press on regardless?
I have talked about the need for contracts to enshrine rather than undermine our professional values. Much of our work in 2016 will be about building on those values.
We will be working with our members on a major piece of work on end-of-life care. This is an area in which Britain has led the world.
The hospice movement, for example, is an achievement we should celebrate as much as any other advance in medicine and one which has made life not just tolerable but precious for thousands of our patients at their most vulnerable time.
There is, however, a shameful variation around the UK in the provision of end-of-life care. There is also an unprecedented scrutiny in the media and from parliament of the choices and options available at the end of life, including the issue of assisted dying.
Our project will produce reports setting out the context of the debate, and independently commissioned research into patients’ and doctors’ views and experiences. Following consultation with members, we will make recommendations which will inform debate at this year’s annual representative meeting.
At the other end of life, our child health project is examining what has changed since the publication of the BMA’s Growing up in the UK, in 2013, looking in particular at the impact of austerity and benefit changes on children and families.
It also aims to assess the progress made on the report’s recommendations and in doing so encourage more collaboration and information sharing.
In all these areas, it is vital that doctors are at the centre of the debate. We may be critical, but we are much more than mere critics.
In October, we set out six key principles designed to future-proof doctors’ training.
We call for a system that is fair, inspiring and responsive to the population’s health needs. They underpin our involvement in taking forward the Shape of Training report, which includes work on credentialing, enhanced training for staff, associate specialist and specialty doctors and possible changes to medical school curricula.
We maintain our opposition to the original report’s recommendation of shorter specialist training, and so it turned out do the medical royal colleges.
Nevertheless, we can work constructively to meet the challenges the report rightly identified — a population with more chronic illness and multiple co-morbidities — to support its intention of more joined-up care, while still opposing any measure that reduces the quality of care we can offer our patients.
This is just a snapshot of the BMA’s work over the year. As a BMA member you can shape that work in a number of ways.
For example, nominations open on 7 January for the election of 18 voting members on BMA council, which sets the association’s strategic direction.
It’s all the more important to be upholding our values when they are under threat from an unprecedented swill of short-term political expediency and long-term budgetary crisis.
NHS providers in England recorded a £1.6bn deficit over six months, compared with £100m for the whole of 2013-14.
The overall size of the deficit is huge, but this is not some abstract figure on the government balance sheet. It is manifest in longer waits, closed wards and unfilled staffing vacancies.
Something has to give, and in some cases that something will be safety. We have seen what happens when trust boards focus unduly on finances, and must not fail to prevent that possibility arising again.
We are piloting a scheme in the north-west of England to support members who raise patient safety concerns, and empower them to do so confidently and constructively.
In the past, they had an element of choice, because they were often motivated by the arbitrary conditions laid down to achieve foundation status. Now, it’s a necessity. Those who should be obsessing about patient care are having to obsess about which ward to close, and how they will pay the bills.
The impact on doctors and other healthcare staff is profound. The service improvements they propose are shelved, their patients angry and colleagues who leave not replaced.
If those at the frontline of healthcare are having to focus too heavily on finances, in Whitehall there is in contrast a shameful sense of detachment.
The government has made a start towards the extra £8bn a year it promised by the end of this parliament, but imagines the additional £22bn the NHS needs to find will come from efficiency savings alone.
As one trust chair recently wrote, ‘this is for the birds; yet it is the basis on which budgets are being set’.
Worse than that, the government said the money it has committed this parliament, despite being less than a third of the £30bn required to run NHS business as usual, will in addition fund seven-day services — which it has yet to even define.
General practice is one of the areas in desperate need of greater funding. It is facing unprecedented pressures. Soaring demand, a crisis in recruitment while a third of GPs plan to retire in five years, and an unresourced shift of work from secondary to primary care.
And all this at a time when its share of NHS spending, and the proportion of doctors who are GPs, have sharply fallen.
There will be a special conference of local medical committees on 30 January, which will aim to determine ‘what actions are needed to ensure GPs can deliver a safe and sustainable service’. That is where we have got — survival mode — not just in one part of the UK, not in a traditional Cinderella specialty, but in general practice, the foundation on which the rest of the service depends.
General practice will no doubt be an issue in the elections to the national assemblies of Wales and Northern Ireland and the Scottish parliament in May. In their manifestos, BMA Northern Ireland speaks of a ‘critical shortage of GPs’, while BMA Scotland refers to unsustainable workload intensity.
Another common theme of the manifestos, which argue for greater investment in health, is the stress they place on prioritising public health and supporting people to make healthier choices. As BMA Cymru Wales puts it, it is about ‘challenging the link between poverty and poor health outcomes’.
In England, we all too often have a government that points the finger, not points the way. Yet across the UK we still see thousands of examples every day of doctors and other NHS staff doing their utmost to make every single contact with patients a good one.
In a year where we seek to champion care for those at the beginnings of life and those at the end, to help create a training system that meets the generational challenge to properly integrate care, and to bring safety and fairness to our working lives, I want us to be worthy of our members. In your energy, compassion and commitment, you set us an example to which all must aspire.
BMA council chair Mark Porter
I was talking with my juniors yesterday and trying to identify what has changed. Half of our final year medical students are planning to take a gap year or work abroad. When I qualified 30 years ago, that was unthinkable; we were all chasing the next job. We wanted to do these jobs and work in the different hospitals to gain experience. The only people who worked abroad were high fliers who went to the USA for a year or two, to learn new techniques or do research before returning to the UK. I did not encounter a junior in my specialty (paediatrics) taking a gap year until the mid 90's. One of the juniors said: "It's not the money, I worked as a volunteer in Malawi for nothing, and I went in to the hospital on my days off to help if they were busy." We concluded that the difference was that in Malawi she felt valued. Here it seems that NHS staff, not just doctors, but nurses, A&C staff, PAMs, are made to feel they are a nuisance. If we want a service development we are told over and over 'there is no money', even for something which could make the service more efficient. We are subjected to ongoing 'workforce reviews' which demoralise the staff. Cutting the substantive staffing down to unviable levels results in inadequate capacity and then millions being wasted on agency staff (a form of back-door privatisation). The NHS cannot function without the good will of the staff and the atmosphere has become so embittered in the last few years. In my view the seeds of this were sown in the Thatcher years with the 'purchaser - provider split' and the introduction of managerialism into the NHS. To reform the situation, the NHS needs to be returned to its pre-Thatcher state, fully re-nationalised with directly managed units being run by local health authorities.
As a retired consultant with two family members still active in GP and Paeds I'm fully behind the BMA's position. This government is disconnected from the public and doesn't want to understand the trainees position ,nor that of the profession generally . Privatisation is it's agenda it needs to waken up to reality before it's too late .
I'm a palliative care consultant both in a hospice and in an acute sector.
This report is excellent.
I have and always will support every junior doctor in my professional care to combine effectively the 2 main components of patient care which are clinical excellence & empathy.
Thanks for the excellent report. As a former GP and former President of the RCGP I am sad to witness the systematic dismantling of medical professionalism. NHS values across the board are at risk of being suffocated by the unintended consequences of financial short-termism and political over-simplification. Right now itâ€™s the junior doctors in the spotlight. But the political stupidity and intransigence they are fighting affects the entire workforce. I hope the BMA will spearhead a profession-wide campaign of disobedience â€“ a well-argued and uncompromising refusal to comply with changes and practices we know to be silly and hostile to good patient care, wherever we meet them. Alan Bennett once said â€˜one has only to stand still to become a radicalâ€™. Fine â€“ letâ€™s get radical.
To Jeremy Hunt 22 11 15
I am deeply disturbed by the news that further cuts are planned for the NHS. Your responsibility is to preserve and strengthen the NHS. I have worked in USA and I promise you privatisation is NOT the way to go.
So many patients give extremely positive reports of their NHS treatment. You must help to target resources to where they are needed.
Also your job must be to instil a culture in which Doctors and nurses feel valued - you must address the struggle between the agendas of management (eg saving money, freeing beds) and those of clinical staff (satisfactory outcomes, happy and healthy patients). It is undermining to have our valuable doctors for instance unable to find a parking place, even when called in emergency; and to have them spending time in queues at mealtimes. Job satisfaction depends on many things, but we know a feeling of control is important, and working in a team (this means a clearly identified consultant leader and teacher).
Applications and work must have a strong personal element.
However, I am deeply disappointed that the case for the junior doctors' proposed revised contract was put so badly. The BMA must ensure that able, indeed excellent, spokes-people are fielded to get the media, and thus the public, on side.
We are witnessing what might come to be seen as the death throes of a once proud institution known as the NHS. The service is being systematically and deliberately destroyed. Despite all the warnings and protests the whole thing is crashing down. Those in power are relentlessly pursuing their warped policies and agendas no matter what anyone says or does. In these dark days we must stand firm with our patients and colleagues in the medical, nursing and allied professions.
To ensure the care of our patients remains our first concern it is paramount that the principles and values of the NHS are preserved for all even if this means taking strike action.
George S Patton nailed it - "it is better to fight for something than live for nothing". Unless we take action we shall have nothing left to take action for.
I will believe that the BMA upholds the values of the medical profession (or the NHS) when I see them addressing the issue of the disgraceful care.data programme and the completely outrageous legislation that allows the HSCIC access to patientâ€™s primary care records, in breach of data protection law.
Our only protection against this violation of our right to confidentiality is the â€œGiftâ€ of the Secretary of State for Health, supposedly respecting reasonable objections to the scheme, and supposedly allowing patients to opt out. There are compelling reasons for doubting that anyoneâ€™s objections will actually be respected, or that anyone can actually opt out of the scheme but, for just the sake of argument, let us suppose that the opt out is actually honoured. It would clearly follow that HSCIC would not hold any clinical data from the records of patients who have opted out. It would further follow that the record of any patient who has opted out would be held by their GP alone â€“ which is as it should be. It would then follow that the patientâ€™s GP must be the data controller for that record. HSCIC cannot conceivably be the data controller for data they do not hold. Yet a system of data extraction is about to be implemented which gives neither the data subject (the patient) nor the data controller (the GP) any knowledge of or control over what data are extracted from any given record, or over what might happen to the data. The GP, as the data controller, inescapably has the responsibility for protecting the confidentiality of that patientâ€™s record, but they have no means of fulfilling that responsibility. They cannot legally prevent HSCIC from accessing the record and they have no knowledge of or control over what data are extracted by HSCIC or what HSCIC does with the data. The â€œGiftâ€ of the Secretary of State for Health is VOID. Data Protection Law might as well not exist.
I would be extremely disturbed to find that GPs do not object to this situation. That they take no action to register their opposition to the scheme is, I hope, explained by the fact that they work under contract to the NHS, and by the fact that the NHS, aided and abetted by HMG is a notorious bully. I would suggest that this is completely immoral exploitation of the contractual relationship between GPs and the NHS. Is the BMA really going to condone this failure of the NHS values that Dr Porter claims are so important to the BMA? Is the BMA going to stand by and allow the probity of the medical profession, and indeed of the medical research community, to be undermined in this way by politicians?
I am a junior doctor and I would like to thank Maybelle Wallis for her kind words.
I have been a junior doctor for nine years and am finally coming to the end fo my GP training. I have worked in several trusts and 30 different posts over this time.
However, what was interesting was that I could do exactly the same job in two different hospitals- one I loved and the other I hated. The difference? The concept of feeling valued.
Feeling valued is an intangible concept; it is not the sort of thing that you can readily put in a tick box and audit. It is a fundamental and simple thing such as a another person turning around and saying "you did well today" or "I appreciate you helping me here" or "how did your exam go? How is your child?"
In short it is "you matter to me. What you think matters to me." There is no greater influence on a junior doctors training and education than their fellow role models.
In turn let us all remember that as junior doctors we can help to make others feel valued and by this I do not just mean other staff but patients, strangers, family and friends. We all have a fundamental desire to feel valued. Let us not forget this.
I will end with a thought; Jeremy Hunt has done and said many irredeemably daft things but in one respect he has achieved something that no one else has done; he has united a whole organisation and in doing so has made us all feel valued.
We are the NHS. We are part of something special. And I hope that 2016 is a year where we all continue to spread the wonderiful feeling of what it is to feel valued.
We are all part of something special
As the threat to the NHS seems rather extreme, I'm wondering if we should throw in our lot with the nurses and other NHS staff until the end of this parliament
Whilst this can all make for a rather depressing start to the new year. It's important to remember what good we can do on a day to day basis. I was recently an inpatient at the Leicester Royal Infirmary. The care I received from all professionals was exemplary despite there being obvious pressures on resources. Please stay positive in 2016 and focus on the great work we can achieve!!
I am a specialist nurse for CAMHS working in A&E. You have made some excellent points - best of all,we are all NHS - and I think it's time all professions linked up together in support of our shared values.
I cannot see anything other than long hours, increasing bureaucracy, more inspections and assessments, greater workload and continuing paucity of investment in General Practice. There are already online and smartphone app GPs working privately feeding off the access difficulties and the constant mantra from the press that GPs are clinically substandard, overpaid and uncaring. This will continue and as GP numbers fall, lists get bigger and more boxes to be ticked mean less satisfactory consultations, plus extended hours will mean a shift or rota system for doctors, the concept of the family doctor will finally have been killed off altogether unless you can pay.
I have thus retired early and permanently from a job that I aspired to before even entering medical school and enjoyed greatly for many years.
The future is bleak, the future is coming, and I am glad that I am out of it!
I have been struggling my way through "Das Kapital" by Karl Marx, but earlier this week I read one section which struck a chord. He was talking about how 19th century industrialists favoured their employees to work all hours in order to avoid expensive machines lying idle. It reminded me of a programme broadcast years ago where a management guru was being shown around the NHS and he was amazed at all the expensive operating theatres and scanners lying idle at the weekends. Seven-day working is not about patient safety, it is about the most efficient utilisation of expensive facilities. The current contract would make it more expensive for trusts to fully utilise their investments, whereas the new contract would allow maximum utilisation at no further costs. Imagine the savings from being able to manage with less theatres and scanners for the same throughput of patients. It is the same principle that allowed low-cost airlines to undercut the old-fashioned airlines - the more time the planes are in the air, the cheaper the fares.
Marx called it "the brutalisation of the workforce" and this is what it is. It is the sacrifice of the normal working week with all the resultant damage to social and family life in exchange for greater economic efficiency.
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