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Thursday, July 18, 2024
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Why I, as a retired consultant, think the junior doctors are wrong to strike

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UNDER the leadership of their union, the BMA, junior doctors are striking for four days from today. This will have a devastating effect on our already struggling NHS, especially since it follows the four-day Easter holiday and will run to the weekend, in effect closing the NHS for ten days. Trusts have been preparing for this by cancelling thousands of operations and outpatient appointments, emptying wards, and drafting in senior staff to cover pressure areas such as A&E.

Despite this the NHS leaders have announced that they cannot guarantee patient safety. It is estimated that the strike will result in the cancellation of a quarter of a million operations and appointments. This is a catastrophe for the service and for patients.

As a retired hospital consultant I have been trying to make some sense of it all, but as in every such situation one’s view is largely shaped by experience and background, although may I state at this stage that I have never been a member of the BMA and remain very critical of it.

The term ‘junior doctor’ is misleading and rather demeaning. It covers everything from the newly qualified to very experienced doctors heading towards a consultant post.

The structure of hospital medicine in my day was very hierarchical and doctors were allocated to teams known as firms, headed by a consultant. At the bottom were the recently qualified housemen, so called because the hospital was literally their house (home) for the first year or so of their working life. They did the basic work of admitting patients, taking a detailed history and doing the initial examination and investigations. They would then be on the front line during the admission, monitoring patients and doing practical procedures such as setting up IV infusions and writing up drug regimes.

After the first year they would be fully registered by the General Medical Council and start to climb the career ladder to senior house officer then to registrar, so called because in the olden days they would register the patients on the ward, including discharges and deaths. This metamorphosed into doctors who were in the middle stage of their training. Top of the pile were the senior registrars who would spend about five years in specialist training in readiness for becoming a consultant.

I accept that hierarchies are out of fashion in these woke days, but the firm structure gave stability and context. You were part of a team and you knew who and where you were. More importantly, so did the non-medical staff and patients. Our white coats, now outlawed as an infection risk (despite no evidence whatsoever), were badges of significance (and gave us pockets to carry things).

Team cohesion was crucial. I remember a ward round with ‘Sir’ (a top surgeon, President of the Royal College, and a Knight of the Realm). After the round we all congregated, with the senior nurses, in Sister’s office for tea and biscuits. While waxing lyrical on something or other Sir dunked his biscuit then held it aloft, at which point the sodden morsel disintegrated and fell down his college tie.

The next ten minutes were reminiscent of the famous Test Match Special ‘leg over’ broadcast when the presenters became incoherent with laughter. We all attempted to make small talk while desperately trying to suppress our growing collective hysteria. It is such shared experiences that bind teams together.

When I started in 1974 (ouch) I worked on average 120 hours a week over a two-week period, generally with alternate nights and weekends off. When first on call for emergencies you would work all day, be available all night, then back on the ward for 8am the next day. A weekend was Saturday to Monday morning, then start the week again at 8am.

As ‘the babysitter’, that is covering the wards but not for emergencies, generally things were quieter other than the occasional irritating summons by the night sister to certify a death ‘so we can get things sorted before the day staff come on’. 

If this all sounds horrendous there were definite benefits. First you ended this period thoroughly grounded in your profession and having learned to cope with virtually anything. The second benefit was that for those first two years in residence all board and lodging was provided free of charge. We lived in a doctors’ mess, a strong supportive community where we could discuss cases, and generally de-stress. Mrs Jones would arrive at 7.30am and cook us breakfast. At lunch we were often joined by more senior colleagues. Dinner was also provided and there was usually a bar (for those not on duty), a TV and pool table.

If working or operating in the wee small hours we could return to the mess kitchen where crispy bacon was left in the warmer cabinet. A bacon toastie at four o’clock in the morning with a glass of milk was heaven, followed by a couple of hours of kip before starting again.

Although we were very poorly paid (over the extended hours we earned less, on average, than the cleaners and porters), it was during this period with limited living expenses that I was able to buy my first car and save for a mortgage deposit.

I am not looking back with rose-tinted spectacles: we worked bloody hard for our disgraceful pittance. But things started to change in 1975 due mainly to the efforts of the Junior Hospital Doctors Association, a breakaway committee from the BMA. The threat of strike action and an overtime ban forced both the government and the BMA to acknowledge the extent of the excessive hours worked by the juniors and resulted in some improvement in remuneration and working hours.

For the juniors today things are very different. The European Working Time Directive (WTD) was introduced for juniors in 2004 and fully implemented by 2009. It limited the time that they were allowed to work to an average of 48 hours a week. This was, seemingly, a good thing although it severely reduced time available for training. At the time this was strongly supported by the BMA, but as with much in life it had unintended consequences. It necessitated a move to shift working so that the team became very fragmented, and this effectively destroyed the firm system and its concomitant support systems. It is now not unusual for juniors to meet their consultant only occasionally during their attachment. This can leave them feeling isolated and unsupported.

The current pressures in the NHS and the shortage of doctors means that they are frequently inappropriately pressured by managers to take on extra shifts although this contradicts the principles of the WTD. They are also often required to cover vacancies in addition to their own work.

Perks such as free board and lodging have long since gone, and when moving from post to post they need to find their own accommodation. The mutual support of the mess has gone; meals are purchased in the hospital canteen. A doctor working the night shift may be able to get a chocolate bar, a sorry sandwich and a cup of lukewarm brown liquid from a vending machine, but little else.

Due to working patterns they will often find themselves dealing with patients they have never met and of whom they have no knowledge. This is unsatisfactory for both doctors and patients and is not conducive to good medicine where continuity of care is essential.

Juniors today feel pressurised, isolated, abused, undervalued, and institutionally bullied. Job satisfaction is very poor and morale at an all-time low. A decade of below-inflation pay awards have eaten into salaries, making junior doctors significantly worse paid than others in society who lack such extensive qualifications or responsibilities. They also have large student loans to service which my generation did not have. Lucrative job offers in better health care systems overseas are a strong temptation.

The Review Body on Doctors’ and Dentists’ Remuneration (DDRB) is theoretically independent of government and provides annual advice to ministers on the appropriate levels of pay. But for the last decade and probably much longer, governments have ignored their recommendations to such an extent that the cumulative result is the current 35 per cent claim. Some say it should be higher. 

So do the doctors have a valid grievance? In my view, yes: they are highly trained professionals with huge responsibilities, but their remuneration and working practices are dismal and deteriorating. The government should take this seriously. However the question is does this justify strike action which will inevitably cause harm and even death to some patients?

I am retired with a cushy NHS pension and my mortgage long since paid off, so it is with great reluctance that I pronounce judgement. But in the end, I have to say that I do not support this action which I think is too extreme. There were other options available as evidenced in 1975 when Barbara Castle was overheard expressing gleefully that ‘I will take the junior doctors to the cleaners’. She failed because under the threat of industrial action, such as a work to rule, the government finally accepted that their figures were wrong and that the junior doctors, who worked very long hours for poor pay deserved better.

The BMA claim that their aim is to protect the NHS. But even if they were to achieve anything remotely close to 35 per cent this would not address the basic underlying issues which are a chaotic career structure, poor training, lack of sensible manpower planning, and a dysfunctional, collapsing health service. Over the years I have heard nothing constructive from the BMA as to how to improve this.

The BMA is not the only union for doctors, but it represents the majority. It should have been taking robust action long before to address the multiple issues. Equally, ministers should have seen this coming, and they have only themselves to blame.

The first statement of the General Medical Council’s guidance for doctors is ‘Make the care of your patient your first concern’. Sadly the BMA and the government seem to have lost sight of this.

It seems that there is no chance of avoiding this strike, but it should be the last. The BMA and the doctors have made their point, and it is now crucial for both parties to engage in meaningful discussions, not just about pay, but about all the damaging issues which impact on our doctors in training.

I am fearful that the current sorry bunch of politicians will adopt Barbara Castle’s approach and try to ‘take the junior doctors to the cleaners’. If they do this, it will spell disaster for the NHS and the patients.

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Dr Tom Goodfellow
Dr Tom Goodfellow
Tom Goodfellow is a retired NHS consultant radiologist who had a specialist interest in paediatrics and cancer diagnosis.

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