As junior doctors prepare to strike tomorrow, Sophie Walton uncovers the reality of a working life that has driven doctors to breaking point.
The rs21 leaflet supporting the strike can be downloaded here
It’s 8.00 am Monday morning, and we’re in the handover meeting. There are printed lists in the centre of a large, boardroom style table. Each copy lists the details of patients who’ve come to A&E over the weekend and who haven’t been able to go home. All need to be “handed over” to a specialist team who can continue the plan that A&E and on-call doctors have put in place during the weekend.
This morning’s list gives the working diagnoses of 45 patients who’ve been assessed, clerked-in and treated over the weekend (there will be about a hundred others who’ve already been assessed and sent home). There are the patients who are “stable” and likely to continue their care in the assessment unit, or a specialist ward. There are the patients who are poorly, “unstable” and might have been transferred to the intensive care unit or to another hospital. Then there are the patients who have been very poorly, and haven’t made it through the weekend. All these patients were cared for and treated at the weekend, despite Hunt’s claim that we are in need of a seven-day NHS.
It is true that the capacity of the hospital could be increased at the weekend, but that would mean more funding: pathology services to social services. Without all departments operating at weekends, the demands made on a junior doctor working after 5 pm or on the weekend are categorically different to working during the working day. Simply stating that working day now finishes at 10 pm, or now include weekends, does not change the nature of the work.
These morning meetings are packed out with doctors and nurses. The most junior of junior doctors, those just out of medical school, are sent from each of the specialist teams: “Where’s gastro? Anyone seen cardio?”
Still junior at 30?
There’s a good number of senior junior doctors too, those in “core” training programmes and “speciality” posts – at least four or five years out of medical school and on the cusp of 30, but still a junior doctor. These doctors could have been the “Med Reg” on call over night: a doctor senior enough to supervise critically unwell patients without direct supervision, but still expected to report to a consultant. It is a notoriously difficult job, especially in small hospitals with fewer trainees to share the shift rota. It’s only once you become consultant, after at least 8 years training, that you are no longer a junior doctor. All of these doctors will be affected by the proposed contract changes. Of the junior doctors in the room, if they reflect the national figures, three-quarters voted for strike action.
The consultants read through the list and assign each patient to a specific ward. “Patient with background of asthma, infectious exacerbation, managed in the A&E, OK now, should go to respiratory. You happy with that resp?” It’s been a busy weekend for respiratory medicine. The time of year means that people with long term illness, and particularly lung disease, are more likely to come into hospital. These are often people well known to the A&E team – this might be their fifth visit this year. The NHS is dealing with the consequences of an ageing population, so people live with chronic illness for longer, but the NHS is also having to cope with the concentration of front-line services into fewer hospitals. So hospitals have to share resources, people, rooms regardless of local demand or inconvenience for patients. Other A&E departments at local hospitals have been replaced with Urgent Care Centres, are unable to admit sick patients and send them all to this hospital’s door.
Looking around at the people present, there’s something new to these meetings. Every junior doctor wears a “I support the BMA” badge, or has replaced their work lanyard with a green BMA one. You’d think this display of union strength had been organised for years. In fact, it has been exactly the opposite. An open Facebook forum connects 56,000 junior doctors across the country, and anyone else interested in defeating the proposed Junior Doctors Contract. It was set up in July, even though the contract negotiations have been on-going since October 2013. The forum was used to organise demonstrations in London, Manchester, Bristol, and many other towns and cities. It gave rise to creative ideas for campaigning beyond hospitals, like #MeetTheDrs flyering at train stations and city centres.
98% for strike action
When it came to preparing for the strike, the BMA was overwhelmed by the 98% vote for strike action, and the enormous support which the public gave, despite the media coverage. BMA branch representatives had to be voted in at hospitals in the days leading up to the strike, because in many workplaces there had previously been no hospital-level BMA organisation . The BMA were unable to keep up with the mobilisation of their members. Materials had to be couriered to hospitals the weekend before the strike because of unexpected demand.
The last patient is discussed and everyone leaves to go to their speciality wards, “five south”, “six north”, “Bevan ward” where junior doctors and nurses will be trained to use equipment needed by patients with certain conditions. There aren’t enough beds for patients to stay in the ward of their medical speciality. Instead, patients are spread around the hospital wherever they’ll fit. It’s partly the consequence of lack of investment in the core infrastructure. It’s a typical District General Hospital: brutalist architecture, designed as a modern hospital for a population half its current size, half a century ago.
In fact, the majority of hospitals do have some blocks built more recently. Most, if not all of these glossy buildings were funded by the Private Finance Initiative (PFI), built by private companies who set extortionate rates on the loans, forcing hospitals into financial difficulty and diverting funds to paying the mortgage, rather than services. It was the PFI debt that pushed Hinchingbrooke hospital to become the first privately run public hospital in the UK, although it’s now back in public ownership with an even more inflated deficit of £14 million. Circle pulled out of its contract in January 2015, but was only liable for £5 million in damages, the burden of this experiment fell back onto the NHS.
These PFI blocks have been built without much care to the provision of NHS services. Many have excessively large corridors, too small ward spaces, no staff rooms or other impractical and ill-considered designs that make them far less useful to the hospital than they could be. Who gets to use these buildings? Some will hold specialities thought to be profitable to the hospital, rather than the services essential to its running. And the biggest irony in this is that very few staff will have been consulted on the designs, or even asked what they need from a building in order to do their job. It means these super-duper new suites have doors that open the wrong way, or don’t fit with the practicalities of their use.
It isn’t just specialities that make the hospital money. In order for hospitals to sustain their finances, many now provide exclusive resources for private patients: private radiology, private medical wards, private operating lists. Private facilities were once elusive, hospitals now proudly signpost them. These wards have their own express lifts, their own wood panelling, but importantly they do not have their own staff. The on-call doctors are asked to attend sick patients on the private wing without being paid for it (although in one hospital the private wing compensates for doctors’ time by subsidising the coffee machine in the mess room – isn’t that nice?). The nurses are rotated between NHS ward and private ward. The porters come and collect private patients and take them to an operating theatre where they are operated on by NHS staff. Some hospitals allow surgeons, anaesthetists and some members of the operating team to be paid on top of their basic salary for private operations. But running a private service on top of a public service means that NHS patients wait in line while private patients are seen. The huge financial burdens on NHS hospitals now see them advertising to private patients and competing with entirely private hospitals, using the brand of NHS to assure quality and safety to potential customers.
These aren’t the only money-making patients in the NHS. There is a growing trend in providing intensive care or surgery for people flown in from abroad, with the bill for their care charged to their governments. At the same time, non-EU migrants requiring ambulances or admission through A&E are sent a personal bill for their care at 150% of the cost, or required to pay an excess on top of their visa, regardless of whether they pay UK taxes. People visiting the UK for less than six months who require “non-urgent” care can be turned away under the Immigration Act 2014. This hypocrisy of treating the “right” migrants isn’t just discriminatory and unfair towards people who already contribute to the system, it undermines the founding principles of the NHS: free accessible healthcare at the point of need for everyone.
The next job for the morning is for each speciality to see their patients across the hospital, to ask them about how they’re feeling, examine them, look at their charts and with the patients’ nurses and healthcare assistants make a plan for the day, or for discharge home. The nurses and healthcare assistants will know whether someone is ready to go home: are they eating well? Can they dress and wash? Have they tolerated the strenuous physiotherapy? Are they falling? Crudely, once someone’s blood tests are back to normal, these are the most important indicators of whether someone can go home. However, for many older patients these aren’t the factors stopping them from leaving the hospital.
I had one consultant tell me that there are two types of patient in a hospital, those with medical needs and those with “hotel needs”. For these patients, it is “social factors” that are stopping them from going back to their or a family member’s home, or a residential or nursing home. There is very little public funding available for either maintaining people in their own homes supported by family or carers, or for decent accommodation in residential or nursing centres. Private care now offers “buy-to-let” rooms in residential homes for individuals to profit off the frailty of others. Privatisation has been a cheap way of off-loading a complicated social burden from the state, and now the lack of places in decent homes is driving a care-bubble. Full time carers only receive £62.50 per week if they work over 35 hours, and earn less than £110 per week in another job. These buy-to-let rooms are being rented for far more than that. Social workers are in a very difficult position: trying to accommodate people’s wishes later in life, but having to provide it without breaking the budget forced on local government. Patients with hotel needs, but unable to find adequate placements end up lingering in hospital unnecessarily, being exposed to hospital bugs and unusual environments which make people confused and more likely to fall. It is good to get patients out of hospital more quickly, but we have to make sure there are enough safe places for patients to go to, and this just isn’t the case for many older people. So they stay on.
The wards are very busy places during the day. In a district general hospital, a ward team could be made up of five junior doctors and a few more consultants. There is supposed to be at least one senior nurse present, and one staff nurse per 4 patients (although campaigns like 4:1 show how rare this is). Often student nurses are included in the shift rota, filling gaps in nurse recruitment and retention without being paid the rate of a qualified nurse. Across the day, ward clerks, cleaners, hospitality staff, bed managers, physiotherapists, speech and language therapists, porters, other teams of doctors from different specialities and many more will pace the floor of the ward. All these different people work within the confined space of a 28 bed ward, and if one person is missing, it becomes chaos. They also work along side each other while being employed on entirely different contracts: the hospitality staff on zero-hours contracts, the student nurses on bursaries which are threatened with abolition, the consultants on £75,000.
The more junior doctors will be in charge of documenting and enacting the plans for patients, written and formulated by more senior junior doctors or consultants during the ward round. Of the doctors, it’s the most junior who run the ward throughout the day. They write and re-write drug charts, write discharge summaries, talk with visiting carers and family. They’ll be supported by the senior junior doctors, but these could equally well have their time allocated to clinics (or operating theatres, if that’s their thing) alongside the consultants.
Day in day out
At the moment there are glaring discrepancies between the workloads of junior doctors in different specialities. One psychiatry junior doctor could be twiddling their thumbs by lunchtime, another in the Acute Medical Unit could have to stay for an hour or two after their 12 hour shift finishes to sort the paper work. This happens day in day out until they rotate onto another speciality, better or worse than the previous job. There are contractual pay “bandings” to try to adjust for these discrepancies, but these are at stake in the new contract. What the banding system can’t adjust for is quality of life. Each junior in a bad job takes the hit until they move on, hoping it will be better next month. There is no incentive to try to change the nature of the job because you’re not there long enough to push back against management.
The contracts dispute has unleashed the frustration of junior doctors working in these conditions. They see around them all the inadequacies of NHS restructuring, of the privatisation, patients unable to go home, of the lack of investment, and now they have somewhere to say it, and someone to listen. The general public has shown immense support for the junior doctors’ fight – patients on wards telling doctors to go on strike, for their sake and to save the NHS. That has been hugely empowering, especially in the wake of the media and government spin to break public support. That’s why everyone wears their badge: they are a junior doctor.
This article originally appeared in the January 2016 issue of the rs21 magazine. Subscribe to the magazine here