Walls come tumbling down

A long time ago, I was a militant junior doctor. I qualified too late to have anything to do with the 1975 junior doctors’ strike, but for several years I was involved in representing junior doctors in various ways. We campaigned to reduce onerous hours-of-work throughout my time in medical politics. One weekend, we arranged for a reporter from a Sunday tabloid to shadow a colleague on call. The journalist hung around for about an hour. After that, he got a bit bored and said he was nipping down to the pub with the photographer. He never came back. The subsequent headline was “I love this job. I’d do it for free”. We were not pleased. The colleague denied he had ever said it.

The hours-of-work campaign went on for decades, led by successive generations of junior doctor activists. Although concessions were won, the fundamental issue was never conceded by governments of either party. It was the European Working Time Directive that finally turned the tide. It is extraordinary that governments were content to allow doctors to work far beyond limits that apply to lorry drivers and airline pilots. Now it looks as if they want to do it again.

I was a typical pre-registration house officer in 1980. I worked an average of 96 hours a week. Every third weekend I started on Friday at 9 am and finished on Monday at 5 pm. Human beings are resilient and we all coped. We worked in tight-knit teams in those days. The work was exciting. We had fun. It was a bit like the MASH TV series. But it was not safe to make people, even the young, work in this way. It was wrong.

I saw very little of my wife, because when I was at home, I slept all the time. That level of fatigue is intrinsically dangerous for patients. One time I had been working for 18 hours without rest. I went to bed at 2 am and immediately fell asleep. I took a call for a cardiac arrest at about 3 am without waking properly. Half an hour later, a colleague arrived in my room to check if I was alright, because I had not arrived with the rest of the crash team. I was lying asleep on top of the telephone. I am pleased to say that the patient survived, but that was because they had not actually had a cardiac arrest. They had fainted. If they had had an actual cardiac arrest, it might have been a different story. It was a near-miss caused by over-work.

Junior doctors work shorter hours these days, but in some other ways their lives are more difficult. Tight-knit teams are gone, out-of-hours at least. The whole structure of practice in hospital medicine is becoming atomised. Junior doctors are often isolated, working with an ever-changing array of relative strangers, because on-call is no longer a team exercise. The work is more intense, and the penalty for making an error, or even being complained about, is much higher than it was. Junior doctors are anxious, and they practice anxious medicine, which is not necessarily good medicine. I am not saying the medical profession has gone to the dogs, because it has not. After 35 years, I still enjoy being a psychiatrist. Nonetheless, there are things happening in the NHS that I find seriously worrying, not least because I am about to turn 60 and I will probably need to use some of these services eventually.

Social scientists talk about Fordism, meaning both the mode of manufacture that was pioneered by the Ford Motor Company, and the social and economic consequences of its dominance. It is said that, since the 1980s, Western economies have entered a post-Fordist era, which involves smaller, artisan production, aimed at niche markets. No one appears to have told the policy makers who control British health care about this. Increasingly we have a production-line system of care pathways, aimed at treating conditions not individuals. There is scant evidence that therapeutic relationships between professionals and patients are valued much by our political masters, despite much hand-wringing about lack of compassion (which is surely a quality that requires a continuing relationship in order to flourish). Health professions do not change their values very easily, which is one of the homeostatic mechanisms in the NHS. We continue to adhere to core medical values, despite being relentlessly encouraged to follow a Fordist model. Fordism has two consequences, as every good Marxian social scientist knows. The workforce become alienated, and they start to organise themselves to resist.

Both sides in the current dispute draw a parallel with the 1983 miners’ strike. Jeremy Hunt is standing firm against union militancy so that his plans for the health service, whatever they might be, can proceed unobstructed. The junior doctors believe they are acting out of altruism, not self-interest, to save the health service. They argue that a return to routine over-work would compromise patient safety and that NHS retention of British medical graduates would further deteriorate. The dispute has been hyped up into a cataclysmic battle between the strongest and best organised part of the health workforce and an unbending Government. If the junior doctors lose, no other group of health workers can expect to win. I am not sure that a defeat of the junior doctors would have the same consequences for the health industry as the defeat of the miners had for the coal industry, but no matter what the outcome, it is going to take a long time for this rift to be mended. There is a lot of anger and alienation around.

I regret the current dispute, but I support the junior doctors without equivocation. Most of the other senior doctors I know do too. Government arguments about seven-day working and mortality amongst weekend admissions do not stack up. Their seven-day working plan would weaken out-of-hours care, not strengthen it. The Government would have to make massive financial investment to implement seven day working, even if they cut junior doctors’ pay. In any case, there are insufficient trained health professionals in the UK to deliver it. Out of hours care can and should be strengthened, but this is not the way to achieve it.

Although the junior doctors are essentially right in what they say, it is hard to see the endgame. During the 1975 strike, the consultants were positively hostile. This time they are supporting their juniors by covering their work. Consequently, the strike is not really a strike in the usual sense. The junior doctors have pointed out that it is less disruptive to patient care than the extra Bank Holiday for the Royal Wedding a few years ago. These are not the actions of irresponsible fanatics. It is hard to imagine that a soft strike like this will drive Jeremy Hunt to admit defeat. The real purpose of the strike is to harness public attention. It is a high-risk strategy. At present, it is hard to know who is winning the propaganda war.

Colleagues who have gone abroad to work, to the Antipodes and elsewhere, report that working conditions are far better. Medicine is a global labour market. If the junior doctors lose, they will vote with their feet. Recruitment and retention will deteriorate, and it is already very poor. Tax changes affecting pensions are forcing older doctors into retirement. Overseas doctors are not coming here as they once did, because of poor working conditions here and improved opportunities in other countries. There is a significant risk of a recruitment meltdown. A Government victory is so likely to be Pyrrhic that a number of conspiracy theorists have suggested that it is all a ploy to destroy a health service that the Cabinet neither uses nor likes. I doubt it. In my opinion, this is a classic political mess, a bitter dispute driven by an inter-personal power struggle.

There is a great deal at stake in this dispute. A strike is always a two-edged sword, and I have misgivings about where this strike will take us. Nevertheless, sometimes you just have to decide whose side you are on.