Gimme Some Truth

Jeremy Hunt is usually a skilful media performer, but he was unable to keep the lid on his own hubris in an interview with the Mail On Sunday this weekend. This is particularly unfortunate as he is developing a talent for being consistently wrong about almost everything.

The Mail on Sunday piece opens like this: 

“The number of foreign doctors working in the NHS should be cut after Brexit, with home grown medics replacing them, the Health Secretary has declared.”

I have rarely read a sentence that embraces so much wrongness within so few words. Admittedly, it was written by Mail on Sunday journalists, who are well practised at this kind of thing, but it does seem to reflect what Mr Hunt said. I can only assume that it was intended to incense that minority of doctors who were not already alienated by the attrition of the NHS. A few brief points of information, which I imagine are familiar to the Secretary of State:

  • No UK Government since the 1950s has achieved self-sufficiency in medical manpower, despite a very large increase in medical school places
  • Once qualified, almost half of medical graduates do not go into postgraduate training programmes at present
  • Junior doctors are seriously demoralised
  • Senior doctors are choosing to retire early

Foreign-born doctors do not have to stay here. It is perfectly possible for them to go and work in North America or elsewhere. Many do. There has been an increasing trend in recent years for South Asian doctors to return to their country of origin mid-career. Making foreign doctors feel uncomfortable, by implying that there is something wrong with them and that they are not wanted, will encourage them to leave at a time when medical recruitment is extremely difficult. Many areas of the UK cannot even recruit locums, no matter what remuneration is offered.

So far, Mr Hunt has offered no solutions to these problems. In fact, his interview seems aimed at making things worse. However, he may have a trick up his sleeve. Apparently, Brexit means strong border controls, so he could improve retention by taking doctors’ passports away from them.

All of this comes hard on the heels of a puzzling but sparsely reported judicial review on the legality of imposing the new contract on junior doctors. If I have understood this correctly, contract imposition by the Secretary of State for Health would have been unlawful. Jeremy Hunt remained within the law because he did not impose the contract, despite repeatedly saying that he was going to, including in Parliament. These statements were not misleading, it seems, because everyone apart from me knew what he really meant. Someone else is imposing the contract. Whilst Mr Hunt is in charge of NHS England, apparently he is not responsible for it.

There are four jurisdictions in the UK, and although there are significant problems over NHS resources in all of them, the relationship between the medical profession and their employers is not as embittered in Scotland, Wales and Northern Ireland as it is in England. In my opinion, there are some key points if the UK wants to recruit and retain doctors:

  • Government must develop a reciprocally honest and respectful relationship with the profession and with the public. This means clarity on political intentions about the future of the NHS. It also means avoidance of opportunist populism. I do not think that Jeremy Hunt is a xenophobe, but you could believe it from his interview with the Mail on Sunday
  • Doctors’ job content needs to reflect the fact that, by and large, good medicine is practiced within sustained therapeutic relationships. This has a measurable effect on health outcomes. When I am a patient, I do not want to be treated by anonymous strangers. Few doctors enjoy working on a medical production line, and this is a major cause of the urge to leave NHS practice. We need to find ways of making health care less atomised, in order to retain doctors and improve treatment for patients.
  • Employers must take on board the fact that our medical workforce is 50% female, and that this proportion is likely to increase. Discrimination is unacceptable. Measures to mitigate a discriminatory contract are not useful unless doctors trust their employers.
  • Doctors of both genders and of all ages have responsibilities outside of the work place. These are not only parental responsibilities. Many older doctors have to care for frail parents or partners with health problems. Excessive hours and inflexible rostering are not just an inconvenience for people with these responsibilities. They are unsustainable.
  • When I was young, I felt that doctors were far too unaccountable. In contrast, we now have an unbalanced and counter-productive system of accountability. For example, across the whole of the UK there is a pattern of employers referring doctors to the GMC when something goes wrong, without first establishing whether there is a prima facie case for inadequate performance. The doctor is left working, often for several years, under a sword of Damocles, stressed and unsupported. This achieves nothing to improve patient safety and it erodes the morale of everyone involved. It would not be difficult to develop a better system, if there was the political will to do so.
  • Employers and politicians need to start showing some respect for evidence. At the moment, they seem to regard the term as synonymous with ‘propaganda’.

There is a steady stream of political claims that a free-at-the-point-of-delivery NHS is unaffordable. In contrast to this rhetoric, there is good evidence that a public funded and delivered NHS is the most cost-effective model available. The Organisation for Economic Development and Co-operation collates international comparisons. The Government provides the data about the UK for these comparisons. I strongly recommend OECD’s Health at a glance 2015-What insights for the UK? The tables are a model of clarity. They show that the NHS is financially efficient, especially compared with the US system, and that it generates relatively little need for people to spend their cash to top up what they have paid for through taxation. The document concludes that in the UK:

Access to care is very good, but population health is undermined by high levels of smoking, drinking and obesity.

England is the pioneer in quality policies, but basics are still not done right – investing in community care; adequate staffing so that procedures and guidelines can be properly followed; flow and quality of clinical information

Per capita spending on health is close to the OECD average, but below peers such as Ireland, the Netherlands, Germany, France or Australia.

We need a little more of this kind of truth. Implementing the recruitment and retention points above would require a significant shift by all political parties in all UK jurisdictions, including an improved commitment to truthfulness. Although this sounds hard to achieve, the alternative is to drift into a medical manpower crisis of unprecedented severity in the foreseeable future. Privatisation, or even increased spending on its own, will not prevent this.

John Lennon sings about truth here.