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.