Why The Government Will Win

So, over the last few years, I've become more jaded with my job. I see consultants becoming increasingly overworked, stressed and constantly succumb to political clinical targets, rather than for the greater good of their patients.

Sure, a decade ago, the EWTD slashed legal working hours overnight, but the workforce doesn't increase in the same rate. Hence, a massive influx of overseas doctors and locums.

Hospitals around the country are being centralised, with the overall effect of squeezing more out of departments with an already finite resources. Take the example of Barnet and Chase Farm Hospitals in North London. Chase Farm was a hugely expansive hospital over 20years ago, having acquired surrounding cottage hospitals whilst being a tertiary centre for Urology and Head and Neck Surgery. Over the last 10 years, it has crumbled with land being sold off to private firms, and services, including closure of their A+E, being transferred to Barnet Hospital and North Middlesex Hospital. What's the result? North Middlesex recently nationally shamed for their A+E service (or inability to cope!) and Barnet being a smaller hospital struggling to meet their targets.

With the junior doctors contract dragging on, this has erupted a lot of bottled frustration amongst the frontline medical staff. Doctors are leaving. Period. Nursing numbers have been slashed as cost saving measures also. Every aspect of clinical provision has been chipped away.

What's the net result? Increased locums and inefficiencies which is very expensive. This leads to increased deficits on the balance sheet. So to economise, services are downsized, merged, and moved elsewhere.

This is a continual process, which is a net result of chronic underfunding, understaffing and poor planning. I fear there is little we can do to save the NHS. It's cracks are crumbling every second of our shift.

So here come big private firms from abroad. They have abilities to inject cash, and staff and resources. They will leach off NHS income, and cop the risk of negative equity. Take the example of above, if VirginHealth decide to build themselves a new A+E at Chase Farm, it will improve the services for patients in North London. Virgin can employ overseas staff for pure service provision. They will take the money from taxpayers and line the pockets of Richard Branson (and probably Jeremy Hunt.as part of his under-the-table master plan). Who needs to pay National Insurance when we could just pay monthly direct debit to Mr Branson with the promise he'll take care of our injuries and illness if we land up in his A+E.....

Photos of life as a junior doctor

Here is a collection of bizarre and crazy photos of conditions us doctors put up with in the NHS....

If you would like to contribute, please submit via Clicking Here

Finance director refuses to authorise a new lock

Bed for sleeping at night when on-call

Drs Mess: Stale, dusty and always cold

Low Morale among Junior Doctors: The unofficial report

It turns out from Parliamentary debate that Prof Dame Sue Bailey has been asked to lead a review into the reasons for low morale with junior doctors. I thought I'd save her the hassle. Having worked in the NHS several years as a doctor, as a medical student, and during sixth form, I would say I have pretty extensive experience.

The Doctors Lottery

Like myself, doctors apply to a national job application and depending on their performance, will be allocated to work anywhere in the country. Obviously, there are very popular areas and areas where no one wants to move to. I myself am still living out of my car with my suitcase, and effectively am a gypsy.

In specialty training, trainees rotate within a region, and this has implications on family life. Partners have to live away for extensive time periods, difficulty with childcare, or the family unit has to move home completely.

It is a lottery as there is no geographical stability. For some it's a new start, but for some, it's constant instability.

Relationships between junior doctors and their employers/medical colleagues

Doctors rotate departments, or even hospitals every few months. This requires learning new IT systems, navigating a new hospital, learning the local protocols and pathways. The Trainer-Trainee relationship is irrelevant as the majority have no firm structures. 

In addition, we are all working for the same employer: the NHS. Why can't there be a central NHS staff record which will have all our contact details/immunisations and CRB status etc. This would make processes much easier for HR and doctors prior to induction.

Training vs Service Provision

This is difficult to get the balance. Different trainees have different training needs: a core Trainee will want a different learning requirement to a GP Trainee in the same specialty.

Currently, the biggest barrier I see is poor staffing. In the last 3 hospitals I've worked at, my department has been deprived of 1-2 SHOs. This has impact on training, because the remaining SHOs are just about managing the workload, but can't escape the ward/oncall to sit undisturbed in clinic or assist in theatres.

Trainees should be given adequate guidance from Trainers on where and when training opportunities are. However, trainees also need to make the conscious effort to seek these learning opportunities too.

Accommodation

I've seen both great, satisfactory and also downright disgusting accommodations and on-call rooms. 

What we/the BMA have to decide on is what we as Doctors should be expected to put up with. A room which has furnishings unchanged since 1970s but is warm with running hot water and no mould is, practically speaking, "acceptable" by national standards. Whether we as doctors should put up with that, is a different issue. Cohabitant insects is not mentioned in the standards, sadly.

NHS accomodation is cheap, and you get what you pay for. It's a room to sleep. It's not a pimp pad.

If there are particular concerns, and I've seen them on facebook, speak to the landlord or Estates immediately and professionally. Chase up the query. Ensure it is resolved in a timely manner.

Annual Leave

Another bug-bear is the ability to book leave. The ease of booking varies between departments and hospitals. For registrars, advanced notice is need in order to cancel clinics etc. SHOs and FY doctors are responsible adults and should be able to work out among themselves to ensure adequate staff provision. 

A+E departments tend to roster leave days, which is unfair. Leave is a contractual entitlement, and should be honoured; otherwise, it can be considered as charitable hours.

Bureaucracy

I have so much annoyance for administrators and various managers in the NHS. Having to submit endless forms and requiring multiple irrelevant signatories. It is easier to pay a parking fine than to apply for a parking permit. It is easier to pay your road tax than to fill in a Datix form. 

The trouble I see, non-clinical staff are narrow-minded in their job role. They love to have forms and generate lots of paper, for no good reason. 

If there is a broken door, forms have to be filled in and one has to wait for an unspecified time to have it repaired. 

Meals

I hate canteen food. It is a privatised sector of the NHS and their sole purpose is profit. Food is limited, tasteless and still expensive.

It is worse when on call, when there is sometimes no way to get a decent hot meal. I've done many night shifts hungry, surviving on tea and toast from the ward kitchens and free biscuits from the friendly nurses.

My 10 point plan for improvement:

1. National NHS staff record, shareable upon request to specific organisations
2. Increase rotation time in hospitals to allow Trainees to build relationships with the hospitals/trainers
3. Allow trainees to swap jobs/hospitals with other trainees, without pointless bureaucracy
4. Promote doctors involvement in IT systems
5. Access to free meals when on call
6. Set a standard requirement for oncall rooms and accommodation
7. Improve staffing levels
8. Doctors should write departmental handbooks for their departments to handover to prospective trainees
9. Trainers should provide a standard working week timetable for trainees to identify theatre/clinic sessions for learning opportunities
10. David Cameron - keep your mits off my NHS!!!

Proof of calculated pay cut

With all the fuss about misleading calculators, I sought to look at my own rota and work out from first principles as to whether my "pay" would be, as suggested, equal or not.

Current Contract

My current rota template is this:

It's a fairly standard 1 in 6 rota. It works, and we're happy working in this pattern. It's banded a 1A.

Therefore, current base pay is £34402 as a CT2. With a 1A supplement (50%), my gross pay goes up to £51603.

New Contract

The unsocial hours are recategorised as above. Now here's the fun. Using the rota template, I will slot hours into each category.

	Week 1	Week 2	Week 3	Week 4	Week 5	Week 6	Total (Total/6)	Enhanced hrs
Mon-Fri 07-22hr, Sat 07-19hr	12	45	48	54	4	36	199 (33.17)	33.17
Sat 19-22hr	-	-	-	1	2	-	3 (0.5)	x1⅓ = 0.67
Sun 07-22hr	-	-	-	12	3	-	15 (2.5)	x1⅓ = 3.33
22-07hr	36	-	-	-	27	-	63 (10.5)	x1½ = 15.75
Total	48	45	48	67	36	36	280 (46.67)

As mentioned, it's a working rota and seems to fit within legal limits.

The sum of the total hours therefore equals 52.92. The new proposed basic pay is £37400 equating to an average hourly rate of £17.98.
Therefore 52.92 x 17.98 x 52 = 49477.

Therefore, my counterpart next year working the exact same hours in August 2016 will be earning a gross pay of £49477.

This is a pay loss of £2126. That's a lot of money considering I have to pay £420/month for staff accomodation which I'm not entitled for reimbursement. This money lost is equivalent to about 5 months of my rent!

However, please let me know if my calculations are wrong (!!)

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Source: http://www.nhsemployers.org/~/media/Employers/Documents/Need%20to%20know/JD%20A4%20booklet%20FINAL.pdf

Trading NHS doctors for a cheaper alternative

Jeremy HC*nt is a clever man. He requires a £20billion "efficiency" saving by 2020, but this has nationally been managed at local level by axing masses of administrative workforce. Not to mention, deliberate incompetence in HR staff in failing to replace medical personnel. This amounts to the requirement for short-term recruitment for locum doctors instead. Overall, a monetary inefficiency. Who wins? Locum agencies.


Now that he has pushed through the en-face undercutting new August 2016 job contract for junior doctors, there is indeed an additional trick up his sleeve. The use of Physician Assistants.

The National PA Expansion Programme is recruiting 200+ PA's from the USA to relocate them in the UK to replace junior doctors. However, there are some very striking shockers!

In the USA, a typical program is 3years of training (~£10k-£60k depending on where you train in USA) , to then apply for the NCCPA exam.

As far as I know, my duties as a trainee is to teaching and supervise my fellow Foundation Doctors.
All doctors take medical histories, assess and examine patients, initiate and interpret investigative studies, and mak management plans. Certainly when the Consultants are around, I present my case to them. However, it is highly unfair that I do not get a scheduled and protected study period. Fitting my academic work has to happen in my evenings and days off.

This is where things really begin to annoy me. £50k starting salary, with greater annual leave entitlement. Starting salary for an FY1 will be £22k (if assuming 1.5x banding, this will be £34k). It's not until a Year 1 SpR (ST3) that you will be on par with a PA. Where's the sense in that.
Besides, are my GMC or RCSEng or even relocation fees paid for? Not at all.

Don't get me wrong, I for a long time have mentioned that PAs should be employed to assist in clinical teams. However, they should not be replacing the FY1/SHO. They should be there to support the phlebotomy and nonsense administrative tasks to allow the junior doctors to actually train to be a doctor.

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Ref: https://www.jobs.nhs.uk/xi/vacancy/dadc67164541975f6a966bbe95dcd6c4/?vac_ref=913883690

NHS wars- doctors strike back

So in the latest political gambit it seems Jeremy Hunt's vision of the NHS is far from what he already understands. This weekend has seen my fellow colleagues around the country posting #ImInWorkJeremy to prove the NHS is staffed with doctors at weekend. So here's my letter to you Mr Hunt...

Dear Mr Hunt,

Your vision of a 7-day NHS is something all doctors want. However, the message you've portrayed to the media and what the public percieve of us is truly damaging to the huge efforts and personal individual investments we doctor put not just into our career, but personal life too - all for the sake of doing the greater good the general population.

I would first like you to clarify where you received your statistics and how you have concluded what you claim.
The study by Freemantle et al (http://jrs.sagepub.com/content/105/2/74.full) states that patients admitted as emergency on a Sunday vs. Wednesday has a hazard ration of 1.16. HOWEVER, and this the big BUT, the same paper quotes "being an inpatient in hospital on Sunday, regardless of the day of admission, was associated with a lower risk of death (on that day) than Wednesday ....Similarly, Saturday was associated with reduced risk of in-hospital death compared with Wednesday..."

The above image sums up well the false claim you have made. Patients admitted on a weekend day have a higher risk of subsequent mortality, but this will not be because of lack of doctors. We already see the day of death is higher during the week. Therefore your publicly announced argument is a political LIE.

More likely is that social care services and GP services are unavailable at weekend, so the ill patient who has been struggling all week finally gives up and ends up in A+E at the weekend. They are self-selected as sicker patients.

May I add, elective admissions generally do not occur at weekends except for minor day case procedures and local anaesthetic cases. However, with government targets, many Trusts run Waiting List Initiatives (which I hope you are aware of) where surgeons, nurses and ward nurses are paid extra to run additional sessions in order to save a waiting list breach. However, often the staff of these sessions are occasionally with locum surgeons and nurses. Again, this self-selects a substandard care.

Further, if you were to be unwell anywhere in this country, you will go to an A+E department and you will be in the vicinity of an A+E Consultant. Followed by your specialty Consultant. Consultants, Registrars and Junior doctors staff a hospital day and night. Doctors includng Consultant already work weekends! However, services are spread thinner, granted.

I ask you this, how do you intend to construct the new Doctors Contracts to comply with European Working Time directive? If you want more doctors at weekends, will you pull staff from during the week?

Additionally, do you realise physiotherapists, occupational therapists, pharmacists, specialist lab technicians, porters, cleaners, radiographers all run reduced/no services at weekends. They are all NON-doctors who are essential to running of a hospital during a normal day, facilitating care and discharge. Social Service do not operate at weekends either. Ploughing more doctors into a weekend will NOT make the hospitals run more efficiently or reduce mortality without the rest of the NHS services fully running at weekends too.

Finally, I will end this by asking you closed questions:
- Will you make a national apology for the misinterpretation of the statistics you have stated?
- Will you make a national apology to doctors for further destroying there ever so reducing morale under govermentment schemes?
- Will you state a plan on how you will run a 7-day NHS with which the ESSENTIAL allied health professionals and social services are available and fully functional at weekends?

Your kind regards,

Mr Steth

ARCP - absurd reviews of clinical pointlessness

That time of year when all trainees, myself included, frantically upload everything and harass our consultants for pointless tickbox-worthy workplace-based assessments for the sake of satisfying various all mighty judges who see you nothing more than a piece of meat in a foodwrapping factory. So long as you have all the correct labels, you're fit to go out to market!

I know many who have failed this year, or received "inadequate evidence presented to progress" on the basis of the most trivial things. I personally require more consultant level WBAs; but does this judge me as a good doctor? If my consultants haven't bothered to validate a WBA or meeting because they conveniently keep forgetting their login details, is that really a reason to penalise us trainees? The deanery should be investigating the technology-incompetent supervisors.

Particularly in surgical specialties, much responsibility is delegated to the registrars so I often will discuss cases directly with registrars rather than consultants. Additionally, it's rather out of my control when on the numerous occasions consultants will say "sorry find me tomorrow instead".

I do think if the deaneries want accurate reports of trainees, they should harass random individuals in the department. A 360 degree appraisal is far more informative than pointless CBDs. The deaneries should really push weight on the consultants.

I myself will frequently compete WBAs for my foundation doctors, and i encourage them to send them. It's a shame the consultants can't take on the same attitude.
It is massively hypocritical of Stella Vig and like-minded consultants who refuse to complete them. I refer to my tweet during ASiT 2015 (https://twitter.com/MrSteth/status/572011787966668800)

At the end of the day, it's here to stay. So as they say in Rome, just do it.