‘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.
Talks in the balance
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.
Seven-day services
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.
Doctors’ training
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.
Finance: ‘This is for the birds’
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
