Richard Smith: The Catch 22 of health strikes

richard_smith_2014Junior doctors are clearly extremely angry. Some 15 000 junior doctors recently protested against changes in their contract. As there are about 55 000 junior doctors in England, that’s the equivalent of about 16m of the general population protesting a change. That would be a revolution. But why are junior doctors so angry and what should they do about their anger?

The standard line is that doctors are protecting “patient safety, the wellbeing of doctors, and the future of the NHS.” That seems to me spin.

Hospital care is dangerous. We’ve known that for 30 years, but nothing happened until the Institute of Medicine published its report in 1999, and nothing moved in the UK until the new century with the creation of the National Patient Safety Agency. Hospitals are probably safer now than 30 years ago, but no doctors were inspired to march through the streets protesting lack of safety until the contract of junior doctors was threatened. Tiredness in doctors is a safety problem, but it’s by no means the main one—and it’s a matter of dispute whether junior doctors will be working longer hours.

Junior doctors are, of course, smart enough to realise that the public are much more likely to respond to threats to patient safety than to doctors having to work Saturday evenings.

Similarly the public will be concerned by threats to the future of the NHS. And the NHS is threatened, but not by changes to the junior doctor contract. It’s threatened primarily by the rising cost of healthcare because so much more can be done—albeit, much of it, like keeping people with cancer alive another six weeks with expensive drugs, of minimal public (as opposed to individual) benefit.

The wellbeing of doctors—which can sound like spin for how much they are paid—is a real issue, but is it primarily about hours of work and pay? I think that it may be something much deeper.

Schoolchildren and young people aspire to become doctors because they expect to have meaningful work that will do good, be interesting, attract a reasonable salary (maybe even a high one if they take up private practice), offer lots of opportunities, and command respect and status. Is there a sense that being a doctor no longer delivers these aspirations? I won’t analyse them one by one, but as a junior doctor you can feel like an unloved, even unnoticed, stressed cog in a vast machine and being a doctor is not what it once was. You are anxious too about what’s going to happen with the NHS, and Jeremy Hunt being so dismissive is hardly helpful.

So perhaps the protests are about more than hours and money. They reflect a deep frustration, a feeling of being undervalued. But what to do? Protest and talk and talk, yes, but take industrial action?

There’s a Catch 22 inherent in health workers taking industrial action. The point is to disrupt services and cause pain, and a handful of tube drivers can achieve huge impact by striking. People may be furious, but nobody dies. Most of the people affected are far from vulnerable, and walking home probably does them more good than harm. But with a strike by health workers you either cause harm to vulnerable people, even perhaps kill them, or nobody notices that you’ve been on strike. Either way you lose.

Then, there’s the seeming paradox that doctors going on strike leads to a drop in mortality.

People guffaw when told this well established fact, but it’s not surprising because emergency care continues and elective care, which inevitably causes some deaths, ceases. So maybe a strike will lead some pundits to ask if we really need 55 000 junior doctors.

This blog will not make me popular, but I’m not arguing that we should ignore the anger and distress of junior doctors. We simply need to think more deeply about the causes of their distress and how to respond—and most of the response needs to come not from politicians but from doctors themselves. Doctors should never see themselves as victims.

Richard Smith was the editor of The BMJ until 2004. He is now chair of the board of trustees of icddr,b [formerly International Centre for Diarrhoeal Disease Research, Bangladesh], and chair of the board of Patients Know Best. He is also a trustee of C3 Collaborating for Health.

Competing interests: None declared.