Richard Smith: The deeper causes of the doctors’ strike—a thought experiment

richard_smith_2014I’m on my way to walk among bluebells, but my mind is on junior doctors engaging in a total strike, not providing even emergency care, for the first time in the 68 year history of the NHS. How did it come to this? I feel that as “a sort of Doctor” for 40 years and somebody who has written probably a million words on healthcare I ought to know, but I don’t. But let me try. This is a thought experiment.

Immediate causes

The immediate cause is the Secretary of State for Health imposing a new contract on junior doctors. He effectively says, “Sod you. I’m fed up with this. We’ve talked for two years and got nowhere. The government has a democratic mandate to introduce a seven day contract, and you, a bunch of overprivileged brats, have no right to deny the will of the people.” I can feel some sympathy for his position, but imposing the contract is an aggressive act. Good people stand up to bullies, and the junior doctors are mostly good people.

Each side is locked into what psychologists call “extrapolation of commitment.” We’ve gone this far, and there is no going back now—even if where we have got to is crazy. The junior doctors have opted for a total strike. The government accuses junior doctors of trying to bring down the government. What next? Mass resignation by junior doctors? The government importing doctors from overseas? Some climbing down or backing up is clearly needed.

A disaster that began with good intentions

Like many disasters this one began with good intentions. Jeremy Hunt, the Secretary of State for Health, is the first secretary to make safety his priority. We’ve known that healthcare is dangerous for more than 20 years, but we’ve been slow to take it seriously. As the problems of patients become more complex, most having not one condition but several, and the possible interventions more powerful, healthcare is probably becoming more dangerous.

So safety is rightly a priority, and perhaps the politicians needed a way to package a commitment for the manifesto. Improving safety overall may not have been attractive both because people generally don’t understand the riskiness of healthcare and because politicians didn’t want to emphasise the dangers. Evidence that weekend death rates are higher than during the week provided a route forward: making the NHS as safe at weekends as during the week is a neat package and avoids the implication that it’s unsafe during the week.

Doctors weren’t attracted to the idea. They were unconvinced that the NHS was unsafe at the weekend, worried that there aren’t enough resources for a seven day service, and not enthusiastic about having to work more at weekends than now.

Battling over the contract

Battle was joined over the junior doctors’ contract. The changes in the contract are complex, but the core dispute seems to be over whether Saturdays will be regarded as a normal working day and paid accordingly. The government says yes, the junior doctors no. Both sides have a grander story around safety. The government says change is essential to save excess deaths at the weekend. The junior doctors claim not only that the change will make the NHS less safe, through cover being spread too thinly, but will kill the NHS. The doctors on the picket lines see themselves as fighting not so much for more pay on a Saturday but to save the NHS.

Surely there must be deeper causes: what might they be?

I find impossible to believe that junior doctors have called a total strike simply over how much they are paid on Saturdays. Dissatisfaction and disenchantment must go deeper. What might be the causes?

One cause might be that to be a junior doctor now is a different proposition to what it was in 1976 when I graduated and became a junior doctor. The hours are less, and the pay is at least comparable and probably better. The status of doctors is perhaps a little lower, but not by much: doctors are still one of the most respected professions. The job is, however, different. Today’s junior doctors probably have less “dogsbody work”—I used to start each day with taking blood from about 15 patients, now venepuncturists are common. But many of today’s doctors are smaller cogs in a much more complex machine: they may lack senior doctors nurturing them and night nurses making them bacon sandwiches. They may have less freedom and responsibility and be more tightly monitored. In 1976 we may well have had too much freedom and responsibility, but the crucial difference might be that the work had more “meaning”; and “meaning” is the most important part of job satisfaction, more important than pay or hours worked.

The job of junior doctors might also have less meaning because of the change in the nature of the work. I practised in the declining days of “diagnose, treat, and cure,” but, as I’ve argued before, those days are largely gone. Most patients have multiple long term conditions and are never cured, and whether or not they do well or not depends much more on them than their doctors. So there is less of the “instant gratification” that doctors can sometimes enjoy. Patients are much older than in my day, and at least a quarter of patients in hospital don’t need to be there: they have social problems, and far from hospital making them better it will be hastening their deterioration. The work is less satisfying.

The work might be more satisfying in that more can be done now. When I admitted patients with heart attacks I gave them a shot of morphine and lignocaine (wholly unaware that that I was killing them) and tucked them up in bed. I chatted with patients with metastatic cancer, injected them with morphine, and waited for them to die. When on call for four nights running, as I was sometimes, I slept most of the time but sometimes got up to sign death certificates, consoled by the “ash cash” that would come my way. Now medicine is much more interventionist and frantic. Patients pass through the hospital more rapidly. Doctors on call sleep much less. But do the doctors worry about whether they are adding much value, doing much good? I fear that they might.

And does the training that doctors receive prepare them for this modern, less human world? Do they understand the complexity of the systems in which they must work? I fear that they don’t, and worse they may feel victims of the system. Even if you are a victim, feeling yourself to be one hurts you and nobody else.

Could there be a growing gap between expectations and reality? It’s much easier to lower your expectations than to improve your reality, even if that’s distinctly unambitious. I’m suggesting that the reality might be diminished from my day, but could expectations also be higher?

Perhaps junior doctors are expressing the justified anger of their whole generation. Us baby boomers didn’t have to do national service, got grants to go to university, never feared unemployment, bought houses that have become absurdly valuable, and now have final salary pensions that we can claim in our 50s. Although being the luckiest generation who ever lived, we have allowed climate change to get out of control, threatening the future of our children and grandchildren. Junior doctors, in contrast, are graduating with substantial debts, struggle to afford housing, and must work until they are 70. Their anger is legitimate.

Fear of the future by junior doctors may be a factor and is justified. The NHS, like other health systems, is becoming unaffordable. If it’s to survive it must change rapidly and substantially, and what will be the role of doctors in this changed world? Might there be unemployment? Might the status of doctors decline? Might the work become even less satisfying?

When old doctors gather together they speculate on the drivers behind the junior doctors’ strike. One theory that I don’t share is that the doctors are different. Younger doctors, the theory goes, see medicine as a job not a vocation. The implication is that they are more selfish. They may well be more concerned with work life balance than older doctors, but that seems to me a good thing—making them more balanced people and so better doctors. I can’t accept that junior doctors are less dedicated than their seniors.

No clear conclusion

Here endeth my thought experiment. I’ve not reached a neat conclusion, but I didn’t expect to. I remain convinced that the strike is about more than having to work on Saturdays, and the drivers may be a complex amalgam of the work being less satisfying and meaningful and more demanding, juniors being lost in the system, anger at the older generation having taken too much, and fear of what the future might hold.

I am convinced that the group who can do most to move us from current sad circumstances to something better is not politicians but senior doctors.

Richard Smith was the editor of The BMJ until 2004. 

  • Amr Gohar

    It seems that the private sector is apparently essential to maintain the NHS. It helps with the workload, brings new skills, and contributes to competition. Relevant article (Egyptian Health Systems):

  • jdwoods

    I agree with much of this article. However my observation as a practicing consultant is that current junior doctors actually do more ‘dogsbody’ work as Richard refers to it than we did in the past.
    As one example, in an effort to get timely information to general practice, our F1’s now hand type complex discharge letters into a discharge system and have to manage all the problems that a creaking IT infrastructure causes prior to production of a printed letter.
    Much of what they do could be done could be done, or at least substantially reduced by a ward clerk or other support staff. Junior doctor time does not appear to be sufficiently valued. This suggests that it is still cheaper to get them to do these tasks than someone else -particularly out of hours.

  • Mock Turtle

    Not to mention an A4 proforma for every cannula…!

  • Tuck-Kay Loke

    On reflection I would concede that there is a lot of truth in RS’s thought experiment. However perhaps change is already happening within the profession, amongst other healthcare workers caught up in this tug-of-war, and most importantly the public.

    Doctors in general value justice, and pride themselves as upholders of truth. It would be fair to say that the propagation of truth has been in short supply since the concept of a safe 7-day NHS was mooted. Trusts across England had already made significant strides in achieving this utopia without the sceptre of the imposition of change to junior doctors’ unsociable hours.

    This contract, toxic as it may seem, and under the right conditions, can be reworked to mitigate some if not all of its critics’ justified claims. However it is likely that someone other than this Secretary of State for Health will have to bear the responsibility of offering the profession its proverbial olive leaf. As the numbers at the picket lines have shown over the past two days, the current workforce has all but lost faith with the current adminstration.

  • johncollee

    Good article. I agree!

  • Kit Byatt

    This is a very thoughtful reflection on the current debacle, where two parties trying to achieve the same broad end [the best achievable quality care throughout the week] have ended up completely at loggerheads regarding what the priorities actually are, and how to set about achieving them.

    Another subtle, but I believe key, difference between the 70s (when I also qualified) and now is that we currently have very little continuity anywhere in the system.
    To admit a patient and then follow them through their ‘illness journey’ – which was the norm then – is now a rare experience. This results in briefer & shallower doctor-patient relationships, and less experience of the natural history of a disease in a given person.
    Junior doctors’ working patterns are now very different. The ‘firm’ system (of which one used to be a member for 6 months, and which gave great emotional and professional support) has evaporated. Juniors just work a succession of shifts, with a variety of colleagues – at all levels. Moreover, doctors much less often live on site, have less control over where they work (with the national recruitment systems), and I believe [data, anyone?!] buy houses, settle down and start families earlier than then.

    These widespread discontinuities inevitably cause less emotional ‘buy-in’, and result in learning experiences that are less powerful. This all yields equally knowledgeable & technically skilled, but less experienced, folk at any given stage of training, and also probably contributes to a more detached [and healthy] view of work/life balance.
    I’m *not* saying we should go back to all the ways of the late last century, but simply observing that these are significant influences on where the profession is now.

  • DrMurphy

    Time off is precious. The work is intense, mentally tiring and often emotionally draining… As a consultant I will typically work 11 hours a day 5 days a week and be available for calls 24/7 everyday. Weekends are also often used to develop projects/services. That is what you do in a vocation and providing your work is valued everyone is happy..
    The NHS relies on the (20 hours) goodwill that I and many others provide – which is typically to focus on service improvement and training juniors.
    Mr Hunt’s contract will be costly to the NHS as that goodwill will be lost with contract imposition.


    When the Junior doctors suggested that they may go on strike with School Teachers , who being teachers are always in conflict with the Government of the day, we recognise that this is politics rather than medicine in play . I think that is disgraceful and the Dr’s are being badly led .

  • Had P

    A very good blog. Thanks Richard

    Over the years I have really enjoy working with junior docs and medical students. Their commitment and intelligence inspires me.

    However, I too think the vast majority of JDs have allowed themselves to be sucked into a battle between the BMA and Govt – and become the totem for so many other issues. They have been played.

    It is very hard to come back from such misery. It will ruin lives and careers, even if they are pursued in Oz or other sectors.

    Why this sorry state? I think a combination of millennial entitlement and work pressure and being praised by so many has dulled critical faculties…

    Sadly, there is far too much groupthink – and not enough independent thought.

    In health professionals we are entitled to expect an awareness of the risks of the confirmation bias (in diagnosis) and splitting (making things good or bad) – and therefore some resistance to simple scapegoating (of the government here, of the difficult patient or general management there) and sanctifying (of BMA here or the supportive friend in another profession there). These are core clinical skills – though only really in mental health and social work are they central. And certainly they are not that visible in the march to the edge of the cliff that is the JD strike.

    The focus on the patient is taking a hit – though good trusts are trying to refocus and seize the initiative at the moment I think.

    Sadly professional responsibility is increasingly seen to be about taking the initiative around personal status and power (“first do no harm to my terms and conditions”)

    The impact on the culture and personal behaviours means this will be toxic for ages. When some colleagues are so miserable it is very hard to stay chipper and get over such a trauma. There is a risk that the lowest common denominator in JD opinion and mood will rule for years.