GQs about ogoing NHS doctor's strike in the U.K.

Factual Questions
1

The NHS doctor’s strike is not getting a lot attention in the U.S., but I did run across a reference to it on Cracked.com (of all places) and in this CBS News online article. The article prompts a few questions from this American, though, based on this paragraph:

The strike reflects the impasse between the government and the junior doctors, who are physicians with up to 10 years’ experience, over the government’s pledge to greatly expand National Health Service care on weekends.
1) What NHS care had been previously unavailable on weekends? I assume emergency care (car accidents, etc.) was always readily available. Was it just that patients couldn’t get in to see a doctor for minor ailments over a weekend? For instance, if someone came down with a bad sinus infection Friday evening, would that person have been forced to wait until Monday morning to be seen by a doctor and prescribed medication?

2) Why aren’t the interests of junior doctors and senior (?) doctors more aligned? It appears to be a case where junior doctors were leaned on heavily to do less desirable work of some sort. But what are the specifics?

3) Are there no hours-&-compensation compromises on the table? For instance, I can understand junior doctors not wanting to go from 5-day weeks to 6- or 7-day weeks without additional compensation. But if the issue is not so much compensation and it’s more about “we don’t want to work weekends!” … well, I don’t know about the U.K., but in the U.S. “physician” is not usually considered a 9-to-5 Mon-Fri desk job though I know a lot of doctors can arrange their private practices to run in line with usual business hours. But for the junior doctors in the U.K. – has it been proposed that they’d still work 40 hours (or whatever it has been), but it’s just that those hours would be spread out differently? Or that they could not longer count on being off on Saturdays and Sundays, but would instead always have two other days off each week?

Thanks in advance to any clarity anyone can provide.

2

The Beeb has a FAQ on the dispute which might shed some light on it, certainly did for me - particularly on the term ‘junior’ doctor, which isn’t always what it sounds, and the specifics of the weekend/post 7pm rate dispute.

3

Thanks, Mr. Kobayashi. Still more questions are raised, but your first link has, in turn, its own helpful links.

One thing I’m working on is a definition of “unsocial hours”. In the U.S., I can’t think of a singular catch-all term … but I may assume that British “unsocial hours” pretty much equals American “outside of business hours”?

Looking at **Mr. K’s **second link – a helpful graphic of the time-&-compensation proposals – I can parse part of the disagreement in familiar American terms: the NHS wants to make it so that junior doctors only qualify for daily overtime after working two extra hours (in a given day) at the base hourly wage. That’s simplified, and would have some exceptions depending on the specific stop-start times of a given shift … but generally, overtime pay would be less accessible. Especially because with the NHS’s proposal, Saturday “business hours” would no longer be paid at overtime rates.

4

Good info from **Mr. K’s **first link … makes me wonder how U.S. healthcare compares on this one point:
*Is that because death rates are higher at weekends?

This has been one of the most contentious areas of the dispute.

The health secretary has argued that he wants to improve care on Saturdays and Sundays because research shows patients are more likely to die if they are admitted on a weekend.

A study published by the British Medical Journal in September found those admitted on Saturdays had a 10% higher risk of death and on Sundays 15% higher compared with Wednesdays.

But doctors have objected to suggestions that all those deaths are avoidable and could be prevented through increased staffing.

Patients admitted at weekends tend to be sicker and while researchers tried to take this into account they could not say whether they had accounted for it totally.

However, the paper did say the findings raised “challenging questions” about the way services were organised at weekends, while many believe it is access to senior doctors - consultants - that is key rather than junior doctors.*

5

I didn’t see a similar study for the US, but here is one from Canada.

http://www.nejm.org/doi/full/10.1056/NEJMsa003376?viewType=Print&viewClass=Print

6

The real problem is that if you want 7 day a week full healthcare, then you have to fund it.

This means having significantly more staff, of all specialisations and all levels of expertise.

This may spread the workload and demand over a longer period, and thus ease some pressures, but in the round it will cost more.

That money is not forthcoming, typical politician responses when confronted by the lack of money is ’ This government is spending more on healthcare than ever before and intends to increase spending above inflation’

Well this may be true, but is so misleading as to amount to egregious deception.

This is because general inflation is lower than medical inflation, and ‘spending more’ does not mean that the extra hours have been financed.

So we have a typical dispute, where both sides pick their facts carefully.

My own view is that this administration is not in the business of spending more, its all about cutbacks and austerity, the promised period of austerity has increased and increased, it was supposed to be over by 2014, latest news from this administration is that its likely to go beyond 2020. That money isn’t going to be there anytime soon, so this means that we will have more cuts, the money will have to cover more operational hours.

I’d expect this will mean some effect on NHS incomes, and working hours, and also on pensions etc - that cost has to be made up somehow.

This basically is what the dispute is about, the imposition of new contracts, on terms that are less favourable.

As a public sector worker, I can vouch for the fact that there have been a stream of ‘reforms’ when almost every single one of them was supposed to be a ‘one off’. This is far from the reality, every two years or so we see more cutbacks on our terms, and increases in our contributions to things such as pensions.

If you stack up the hours, and cut back the staff, what will happen is that death rates may decline slightly at weekends, but they will increase during the week - so we will get a more uniform death rate throughout the 7 days.

As for what happens to the overall death rate, well given that medical technology has reduced death rates anyway, I expect it will fall, and the Government will flag it up as being justification for these changes, the reality is that the death rates will not fall due to changes in working practices, and after statistically stripping out improvements to medical technology effects, I think death rates will increase.

7

When I worked in the NHS, junior doctors routinely worked 80 hour weeks. They were expected to catch up with their sleep in a bedroom provided, but were always on call. When patient stays were usually 3 to 5 days, this wasn’t a problem, but as that reduced to one night or less, the workload increased and doctors got little sleep while on duty.

Then came the Working Time Directive, which says that no one should work more than 40 hours a week on average. You can imagine the problems.

Consultants are supposed to be on call at night and at weekends. They are required to live withing a reasonable distance from their base hospital so that they can get there quickly. In practice, it takes a brave young doctor to get their boss out of bed a 3am, or from a family barbeque on a Sunday afternoon, because they aren’t sure how to treat a patient.

Hospitals are a lot less busy at weekends: All admissions are emergencies as no cold surgery will be scheduled. In consequence there will be a lot fewer support staff: radiologists, pathology staff, pharmacy staff etc. This all has an impact. Why weekend patients should be “sicker” is a mystery to me.

Overlaying all this is the trend for closing smaller local hospitals in favour of huge regional ones.

8

Thanks, casdave & bob++. Do you have any insights regarding why senior doctors don’t seem to be publicly supporting the junior doctors? After all … they were all junior doctors at one point, too. Is it as simple as “Those are no longer our concerns – we’re past that point in our careers?”

9

Not quite, it would be hours which have a negative impact in any attempt to have a social life.

For example, working the 6-14 shift that’s the morning shift in many factories is not business hours but it’s not unsocial hours. Working weekends is unsocial hours no matter what actual hours are involved.

10

Ah, I see. It’s telling that there seems to be no comparable popularly-known concept in the U.S. Some specific fields have increased pay rates for nights-and-weekends work. But more often, if someone works nights or weekends, it’s not considered an especial “unfairness” – it’s just the way things are for that person.

11

This link is to a news article that mentions a small study of five U.S. hospitals – the researchers found that there was a mortality increase over the weekends at least at those five American hospitals. Obviously not a conclusive be-all-end-all study, but curious all the same.

The obvious counterpoint to what’s known in the U.K. as The Weekend Effect: patients “healthy” enough to wait may be more likely to gut out their ailments over a weekend before getting themselves in to be seen/treated. I am sure that particular idea has been evaluated, however.

12

I only have some peripheral knowledge about this, what I do hear is from my colleagues in the UK in medical IT there and they make it sound like a typical union negotiation. The doctors want something in exchange for working weekends, they’re asking for more than they want looking to end up with a favorable compromise in the middle. It would appear to be no different than bus drivers asking for shorter hours or higher wages in their job. I’m sure it’s far more nuanced than that but to the public it may not seem any different than a simple wage and hours dispute.

13

That’s basically it. The British Medical association is a union like any other and has become increasingly politicised in recent years. This means that they are less inclined to do a deal with a Conservative government than a more left wing one. They think that they have popular support and in the main they do, but like the other public utility unions like firemen, teachers and nurses, the public is getting fed up with their reluctance to settle when the differences look so tiny.

I have see it pointed out that they have already conceded a great deal more on pensions and other benefits that the weekend working dispute is about.

As to why consultants don’t support them, I am not entirely sure. It may be a case of ‘we had it worse’, or it may be that they have their own agenda.

14

The interests of senior doctors would seem to have several points of divergence from those of junior doctors. If the juniors are successful in obtaining more favorable pay and hours, that will put cost and staffing pressure on other elements of the system, including senior doctors. They were all juniors at some point, but they aren’t anymore.

15

Its likely that consultants also have more than a little sympathy for their junior colleagues - after all, quite a number of them will be parents of junior doctors, medical practice often runs in families.

People who do not work unsocial hours really don’t have a clue what the effect is of shift patterns on the availability of staff.

As a union rep who does get involved in this sort of thing, and who does work unsocial hours, let me illustrate in a very simplistic way.

A real shift pattern in an emergency service is very much more complex.

Let’s imagine you have 100 practitioners who have an entitlement to 30 days leave per year, they will also have public holidays too so that’s another 8 days. In the NHS there are a couple more that the rest of the country doesn’t get, for example Easter Tuesday.

What you have is 3800 days off, now add in the usual other absences such as sickness and crisis leave and you average at least another 5 days per year, now we have 4300 days off. That’s almost 12 of them on leave on any given working day. This leaves us with 88 staff on duty each working day.
Now lets do the same with unsocial hours, well this means all 365 days are working days - what’s the effect of this?

Well those public holidays are incorporated into annual leave, which gives 38 days each, add in your sick and crisis leave and we get to the same 4300. So nothing has changed right?

Wrong, you see what you are not taking into account is that we are talking working days, and we have increased the number of working days from 260 to 365.

What effect does that have on the shift pattern?

We have to add in all the weekend non-working days that those junior doctors previously had, and that’s 104 days each.

So now we have a total of 14700 leave days for staff, to compensate for all those lost weekends.

This new working year of 365 days means we have over 30 staff on leave on any day, leaving just under 70 staff on duty on any given day.

We have now gone from 88 staff on duty, to 70 staff on duty, just by implementing a shift pattern. You can bet that during Mon-Friday the workload will not reduce, but the number of staff available has gone down, now tell me how this is supposed to improve patient safety??

I have left out lots of other sorts of leave, from long term sick, disciplinary suspensions, maternity leave, study and exam leave, professional development leave, and these would tend to make the picture worse. I have been very conservative in these figures, staff sickness in the NHS is rather higher than the national average, maternity leave tends to be higher.

If we want adequate cover, and return to having 88 staff on duty each working day, its going to cost us a lot to recruit train and pay the 18 staff per 100 we have just lost through work redistribution, and don’t forget the NHS actually employs around 55000 junior doctors, now think of just how much that’s going to cost to provide the same coverage - I have not seen any plans to recruit enough junior doctors to cover this shortfall which might amount to a further 9900 more staff.