Interesting comments on the article.
Andrew Haldenby is Director of Reform.
Jeremy Hunt is under pressure. On the second full day of the junior doctors’ strike, his judgement in picking a fight with the junior doctors is being questioned such figures as Alan Milburn. His department may break its spending limit agreed with the Treasury for this financial year. Public satisfaction with the NHS has fallen. The odd rumour is passing around Westminster that he will be moved in the next reshuffle.
Who could blame him for wanting a move? Almost any job in government would be a relief after facing up to the BMA’s gunboat diplomacy every day. But the fact remains that he is a reforming Health Secretary, in a party far too nervous of health reform, and for that he should be prized.
On the doctors’ strike, Milburn said last week that the Government should settle it – get it out of the way because “arguments like this hold up bigger, necessary reforms”. That may normally be the case (and I don’t make a habit of disagreeing with him on public service reform). In this instance, however, the doctors’ representative body, the British Medical Association, clearly see the dispute as a test of the Government’s wider resolve.
Its aggressive rhetoric has raised the temperature and encouraged its membership towards strike action. It would like nothing better than for the Government to back down on what has become a symbolic dispute. Hunt is showing good judgement in holding the line.
He is also right that the NHS should make further steps to join the rest of our 24/7 society (while recognising of course that many staff already work at weekends). When it reported last year, the independent doctors’ pay review body found the “case for expanded seven day services in the NHS … to be compelling”. It noted that, across the economy, 24/7 services have become more prevalent since the 1990s. It said that the NHS would be a beacon of international good practice if it were able to do better.
As Sarah Woolaston has said, the BMA will lose public support the longer it remains on strike. It is interesting that it has decided not to go for a withdrawal of emergency cover, as it originally promised. That is a hint that they fear that they are pushing the limits of people’s sympathy.
On the NHS more widely, he has given full support to a plan from Simon Stevens, the head of NHS England, which would see the NHS change root-and-branch around the needs of the patient. That plan is making slow progress, and the slow pace of change over many years is the reason for the service’s current financial difficulties. Nevertheless, the direction of travel is right and Hunt again has made the right call.
He will now be under immense pressure from within his department to dump the Government’s whole reform agenda in the face of the service’s money problems. He will be urged to settle with the junior doctors, abandon patient choice as a distraction, and take personal command-and-control of the NHS on the model of the early years of the Blair Government. In those days, quite literally, the Department of Health would telephone individual hospitals to see how they were managing their waiting lists. I hope that Mr Hunt resists and that he gets support from the rest of Government.
(Tony Blair latterly sharply reduced the number of central targets and sought to promote competition and choice. This was his view after a decade in office, as told to the Economist in 2007: “The purpose should be so that public services can adapt and adjust naturally – self-generating reform – rather than being continually prodded and pushed from the centre. Public sector unions can’t be allowed to determine the shape of public services.”)
The biggest hope for the future of the NHS is that it becomes more productive by changing the way it does its business. The route to better value lies in preventing ill health, early diagnosis of illness and a unwavering focus on safe, high quality care, all of which is to the benefit of patients. All of this, however, requires political leadership because the NHS workforce will need to change significantly. The Department of Health needs the same strength of purpose that Theresa May has displayed over police reform. Good reformers make waves. Given the BMA, the Police Federation, the Prison Officers Association and so on, it comes with the territory. The waves they make are a sign of their success.
This is not the moment to U-turn on health reform or on Jeremy Hunt.
And there’s rewarding incompetence and being out of your depth
Milburn is right reform is needed but there is absolutely no evidence this reform will produce any meaningful benefit for the NHS apart from financial due to the pay cut aspect and is distracting from actually useful reform
even Bruce Keogh, who has been a friend of both Hunt and the Conservative party during the current dispute, can’t and won’t public back him up about the stats
in terms of the hours things I don’t need the BMA or the DoH to tell me whats going on, GCSE level maths tells me what happens to average hours worked if you increase the amount of hours worked that you want to do with the same or less numbers of staff, and the answer isn’t an hours cut!
On your second point, the total amount of hours worked under the new contract would be the same. The number of junior doctors would be the same. What would differ is:
[a] the premium rates paid for Saturday working; the Government wishes to remove premium pay for Saturday, the BMA wishes to retain it in some form.
[b] the present system allows some junior doctors to work excessive weekend shifts whilst others do little or none. The reasons for this are partly historical, partly down to volunteering, and partly down to differences of clinical need. The Government wishes to allow management to roster junior doctors over the necessary hours as the service demands, paying premium rates on Sunday only. In return, junior doctors will receive 11% increase in basic pay.
There are a number of other adjustments, but I believe agreement has been reached on those.
In terms of the stats it isn’t that simple, those figures show an increased death rate (a month later by the way not on the day of admission), for admissions on a weekend, now as we all know toenail repairs, varicose vein ops, routine procedures are all done on patients admitted in the week – procedures with extremely low mortality
as Keogh said you cannot therefore, without those confounders, claim that doctor staffing alone is the only factor here
as it happens I’m actually in favour of the principle of improving weekend staffing for doctors and all other NHS workers in hospitals but I don’t think aiming to do such a big thing at a time of limited finance is a good idea at all, politically and from the conservative point of view it is a complete self inflicted wound and one Hunt will likely pay with his job for later in the year
As I say I actually back the idea that we should have more people working weekends
I cant see how there’s any way that an increased amount of weekend working will produce anything other than an increase in hours on average, the maths just seems obvious irrespective of any spin from either side
As for stats about increased death rates at the weekend. Firstly, the effect is also found on Fridays and Mondays. Unless I missed something, these are not weekend days. Secondly, as a GP who works one evening a week, untill 11pm and every second weekend, I can state with total confidence that the patients who call, and are admitted at weekends, are considerably more seriously ill than during the week. A factor recognised by various studies. You have to be extremely careful about looking at raw figures then claiming cause and effect. As all scientists know, association is not the same as causation – and anyone who tries to claim that it is, is a complete fool.
I think a 24 / 7 uniform standard of service at hospitals is a no brainer and I don’t think too many doctors dispute that. That however requires the problem of bed blocking to be resolved; the relevant support staff to be provided to doctors, and more permanent doctors rather than reliance on exorbitantly paid locums.
There is absolutely zero demand for weekend GP surgeries and if the Health Sec took action to reduce the amount of time wasters during the week by introducing a nominal charge for a GP visit, which GPs themselves resist in the main, then a lot of the problems facing GPs would disappear.
You want to have fully staffed dermatology departments at 3am on a Sunday morning? Why?
That however requires the problem of bed blocking to be resolved; the relevant support staff to be provided to doctors, and more permanent doctors rather than reliance on exorbitantly paid locums.
Sure, but to do that we probably have to start by recognising that bed blocking is such a problem because we’ve dumped social care on councils and then stripped them of funding for it, haven’t thought about support staff at all, and are driving doctors to leave not just the NHS but the country.
That’s only part of the problem of bed blocking. Equally significant are the cumbersome procedures for discharging patients from hospitals.
I am also interested as to you exact relationship with these eight doctors in your family. Are they your children, your brother and sisters, your parents? You must have a truly amazing family. You should be very proud of them, especially the 4 junior doctors. I presume they all voted no to strike action, which would be equally amazing, as the vote for strike action was > 98%.
the problem we have is those countries don’t seem to believe they have to do what we are doing and us doing all these things whilst they aren’t is increasingly making us look a less attractive option to work in
I suspect we’ve bared saved a penny and caused a huge problem for years ahead in the process
In terms of long term funding its difficult, I know many in the DoH see the insurance model as a potential option but the problem in that is that every European country I see with those sorts of models actually ends up spending well more than we do as a proportion of GDP, and the last thing we need at the moment is a reform that’s going to significantly increase our need for spending
I have mixed views abôut an insurance model. They do seem to work but most health users are those of the elderly who having paid NIC all their lives think they are entitled to free health care and who could not afford to start paying health insurance premiums. I do favour a user pays type model for certain aspects of health care – GP appointments, reducing the huge exemptions from prescription charges, charging for missed outpatients and non emergency visits to A&E; self inflicted health problems such as drunkenness etc
He did a good job damping down the brouhaha caused Lansley’s reforms and it is clearly sensible to focus on improving the quality of care in NHS hospitals at weekends and moving towards a uniform IT platform so that any doctor treating a patient has access to that patients entire medical records. That requires more that a deal with the doctors however. It requires bed blocking to be solved and the provision of the necessary support staff. However, the initial proposals made to the doctors were ludicrously bad so rather than refer the pay review to an independent body such as MPs themselves have, he has got embroiled in an unnecessary testosterone fight with the BMA. Their behaviour of late has been shameful but the public will always side with the doctors against the politicians whomever is in power. If there is any truth in the story that Hunt himself vetoed a deal that all others parties had agreed to then he has a lot of explaining to do. The tragedy of all this is that it deflects attention away from Lord Carters quite sensible plans to save money in running the NHS that can be put back into front line health care.
Err no. The BMA sees this as a dispute about junior doctors contracts, working hours and patient safety. The only people talking of it as a test of the Government’s resolve are political apparatchiks around Westminster like Mr Haldenby. This sort of inane willy-waving as a substitute for real policy is both nauseating and making it more difficult to deliver a decent healthcare policy.
Mr Hunt, no doubt cheered on by the likes of Mr Haldenby, has decided that it suits him politically to be the Gove of Health. Alas, he is charged with being the Health Secretary, so making sure the NHS is working effectively and efficiently ought to come before what suits his political ambitions and career. We hit the nadir a couple of days ago when the NHS, Dept of Health and the BMA thought that they had resolved the dispute, only for Jeremy Hunt to personally intervene and veto that resolution. Mr Hunt prefers to have the strike so he can show what a tough guy he is. It’s pathetic and Mr Haldenby should be ashamed of backing him.
Quitting to locum is also a significant issue as given how threadbare our hospitals are these days we have no choice but to pay it or leave them unsafe
The only foreign doctors that come here are from poorer and developing countries, there is no flow here from Australia or Canada or the US etc
Whether we like it or not people with brains and skills are in a global market
well, the junior docs have been more militant than their senior colleagues.
Enough of them will have few financial commitments and they will travel/take a career break/work as a locum, that the service in many areas will implode.
Junior docs are a reasonably intelligent, critical thinking , independent minded lot. JH thought that constantly shouting unproven half-truths ,that mortality if you are admitted at weekend is higher due to lack of doctors ( its probably due to patients at weekend being more ill and lack of diagnostic and support services ) would work.
Well it hasnt.
how we got here in a fight against what is, to a large part, a conservative voting part of the electorate is beyond me
Shooting yourself in the head, or what .
You imply Jeremy Hunt advocates patient choice. This article quoting the man seems to directly contradicts you.
And this report states that Jeremy Hunt directly called chief executives about waiting times as you are claiming early Blair labour did.
The way hunt has conducted himself in these Junior doctor negotiations is appalling. These are the people who have worked hard and achieved highly since school. They are highly intelligent, highly educated, and highly skilled individuals. They deserve good working conditions and a good wage. If we can throw billions at the bankers, who continue to take the piss with their tax avoidance and huge bonuses we can afford to properly fund the NHS. If we insist on full services over 7 days we need to fund it rather than trying to force a generation of highly skilled professionals to work more antisocial hours for no extra pay.
The NHS is held together by the good will of the people working in it. Doctors, Nurses, Paramedics, radiographers, Physios and all other health professionals all work above and beyond and do not ask for more. These people should be treated with respect, not with hunt’s unique brand of arrogance and incompetence.
For all the health professionals considering emigrating, good for you. You deserve to be treated with respect and be able to deliver your skillset in a safe environment. I’m sure saving an australian’s life comes with about the same level of satisfaction as saving a British person’s life.
Hunt need to go and we need to start treating these people with the respect they deserve.
Clearly a pluralistic future funding stream is needed with working hours reform, of key staffing groups.
The state needs to shrink its commitment and act as a facilitator for the drive of entrepreneurial involvement.
However, Andrew has not read the developing tone music of Mr Hunts involvement.
A minister who becomes THE STORY of the dispute, inducing a visceral negative response from the junior doctors has to leave office.
It’s clear he has felt compelled to be “muscular” , and has perhaps failed to be persuasive for our natural supporters.
In other words, he has become a toxic brand, and needs to hand the reigns over.
The litmus test is whether he remains an electoral liability, and can get the job done.
The time for a fresh conciliatory but subtle approach is needed.
Both sides have overplayed the “patient safety” card when this is clearly about cutting costs (for the government) and protecting T&Cs (for the BMA). However, both Jeremy Hunt and Ben Gummer have been extremely economical with the truth and relied on the complex nature of doctor remuneration to pull the wool over everyone’s eyes.
Regardless of whether or not he still thinks he was “right”, Jeremy should have stepped aside and let another figurehead try to broker a compromise in his place. David Cameron should have insisted as much. None of us have any idea where this is going to end up but its unlikely that either patients or tax payers are going to be better off.