The rollercoaster ride of dispute talks between the British Medical Association representing “junior” doctors and the Secretary of State for Health points either to incompetent negotiations or to the political value of failure. Jeremy Hunt has claimed that 15 of 16 points were resolved, and that money was the only remaining issue. Junior doctors disagree. Now even the terms of disagreement are in dispute.
The government declares genuine support for a national health service, free at the point of delivery, populated by healthcare workers trained to the highest standards. It does so because evaluations of the NHS—by UK citizens and the World Health Organisation alike—are so positive. In 2013, the UK spent 8.5% of national income on health, below the USA (16.5%), Germany, and France (each 11%). NHS spending is set to stabilise at around 10.5% as projected (under the “fully engaged” model) for coming spending reviews, equivalent to Germany’s health budget for 2001.  Using the GDP yardstick, NHS spending is modest and excellent value.
If the government is serious about preserving and extending world class healthcare in the UK, why does it pursue a negotiating strategy that undermines the institutional value of NHS hospitals, built over decades? Why has it pursued an antagonistic and counterintuitive method of engaging with junior doctors—one of the most important constituencies in the provision of hospital services?
Concern over weekend dysfunction among NHS hospitals, and a possible related risk to the public, was the narrative that kick-started the dispute. Yet the narrative is misleading. Seven-day working is already the case in some primary and most of secondary care. The selective use of admissions data to suggest a higher risk of dying at weekends is scaremongering. The real question is why might the current government seek to select a narrative designed to frighten the public? Why, too, have leaders within the UK’s medical establishment bought into this singular narrative which construes collective representation by doctors as a threat to the public rather than—as an alternate and equally plausible narrative—as an attempt by doctors to protect those whom they serve day to day.
The weekend mortality effect is not confined to the weekend alone. It spreads into Friday evening and Monday morning, and the researchers who identified this effect did not apportion the finding to any particular causation. Even a cursory understanding of the hospital ecosystem tells us that the survival chances of patients—especially those with acute medical or surgical needs—depend on an array of factors, including nurses and nursing assistants, critical back-room functions such as laboratory, radiology, pathology, and administrative and cleaning support. If there is to be a debate about what puts people’s lives at risk as they navigate through our healthcare system, at least have it on the basis of an educated understanding of the integrated nature of hospital care. Mr Hunt’s assault on junior doctor contracts is questionable, and there is the possibility that this assault is more a matter of politics.
Over the last 18 months, we have seen a more or less continuous media narrative of financial crisis at the institutional level, and dubious professional motives, at a very personal level, amongst doctors. The media focus, in the aftermath of the previously cancelled strike, on the residual inconvenience of 5,000 re-scheduled appointments was alarming. The narrative celebrating the collective behaviour of doctors acting to protect those they serve was entirely absent.
If the desired outcome was to undermine public confidence in the NHS by questioning the attitude and behaviour of the UK’s hospital doctors, the government’s chosen style of top-down diktat and cliff-edge negotiation is a strategic masterpiece. Negotiations conducted against the backdrop of an increasingly bitter disagreement about the nature of the problem were never likely to succeed. The continuation of a political discourse from the government that seeks to present doctors’ interests as opposed to, rather than in defence of, the interests of patients, will undermine public confidence in a national publicly-funded healthcare system. Perhaps that is the government’s underlying aim.
Sebastian Taylor, Health policy analyst.
Irene Weinreb, GP, Imperial College Health Centre.
Bhanu Williams, Consultant paediatrician, London North West Hospitals NHS Trust.
Eric Brunner, Professor of epidemiology, University College London.
Competing interests: None declared.
1. OECD, 2015. Focus on Health Spending: OECD health statistics 2015, OECD Paris.