The NHS is suffocating under huge pressure. Even the regulator of the UK’s doctors, the General Medical Council – which is not normally known for speaking out – has offered with stark words. The NHS is struggling to cope with the demand placed on it, the GMC says. The “growing number of people with multiple, complex, long term needs” who needed treatment at a time of “severely constrained funding” was made “significantly worse by the fragility of social care services”. This is exactly right. The NHS is doing more, with less, with the added pressure of the financial and bureaucratic costs of service fragmentation under the Health and Social Care Act 2012.
The junior doctor strikes were ostensibly about a new contract, which has now been imposed. But the unrest in the medical profession was and is not confined to that one issue. Doctors are also concerned about Jeremy Hunt’s repeated use of misleading statistics about weekend death rates, continuing even after he had been corrected; and his claims that medicine had turned into a 9 to 5 job, which meant he wanted a “sense of vocation and professionalism brought back into the contract”.
To the doctors routinely working nights, weekends and regular unpaid overtime, this was insulting. Put simply: workers who are well resourced and respected will repay their fulfilment by routinely going beyond the letter for their contract. When staff are treated badly, how can patients be treated well? Morale is the burning, unignorable safety issue in the NHS and yet its governing powers seem unable to admit their responsibility for contributing to its decline. Morale is not just affected by simple unkindnesses – such as the junior doctors unable to know, thanks to the vagaries of the rota system, if they can have time off to get married. It is a systematic problem, with chronic understaffing, frequent rota gaps, fatigue and stress and avoidable mistakes in a toxic mix. No wonder there was such anger when Hunt told parliament that he would arrange a review into why junior doctors morale was so low – ironically on the same day as imposition of the new contract was announced.Good morale usually comes with the feeling that one is doing a good job.
In 2013, research was published in BMJ Quality and Safety which found that staff had an “almost universal desire to provide the best quality of care” and “deeply felt personal professional commitment”. But they also found professionals wasting time over poorly designed IT systems, conflicts between different teams (even within single organisations), heavy workloads and staff shortages, with multiple external agencies creating mess about where time and effort should be spent. Yet, as they wrote “the wellbeing of staff is closely linked to the wellbeing of patients”. It makes sense: staff who are stressed and distressed are not going to give consistently high quality care. Yet sickness rates of the staff in the NHS are higher than the general population and 59 per cent of GPs in the UK describe their work as very or extremely stressful, the highest of any country surveyed by the Health Foundation. There are high levels of burnout.
A target-driven culture is exacerbating this problem. A typical example was when the government seemingly became convinced by poor quality data which suggested that dementia was under diagnosed So it decided to offer GPs £55 per new diagnosis of dementia. Targets were set for screening to take place – despite the UK National Screening Committee having said for years that screening for dementia was ineffective, causing misdiagnosis. And when better data on how many people had dementia was published – which revised the figures down – it was clear that the targets GPs were told to meet were highly error-prone. The cash carrot was accompanied with beating stick, with the results – naming and shaming supposedly poorly diagnosing practices – published online. Setting doctors harmful tasks, leading them almost to “process” patients, fails to respect patient or professional dignity, let alone the principle of “do no harm”.
The rocket fuel of the NHS is the staff. But even the most fundamental part of running the NHS – making sure there are enough people working – has been badly managed. Safer staffing research being done by NICE was stopped by NHS England. And, as the Commons Select Committee put it, there has been “no coherent attempt to assess headcount implications of 7-day NHS”. There is, though, evidence that fewer junior doctors are applying to specialist training. Jeremy Hunt’s response to the ongoing recruitment crisis – a fifth of GP training posts were vacant last year – was an announcement that doctors would be compelled to work for four years for the NHS after graduation. Indeed, a conservative MP has previously proposed this because “investment of taxpayers’ money demands a return for the taxpayer”. This sort of fiscal guilt trip ignores the debts for fees and maintenance accumulated by graduates via the Student Loans Company – over £110,000 for the average male doctor. As an evidence-free policy, who knows what the effect will be – it’s difficult to see long term loyalty nurtured with these terms and conditions.
Working in the NHS should be joyful, a matter of love. But for too long the government has allowed goodwill and vocation to mop up funding shortfalls and bad policymaking. These are now chasmic. As Bevan said, the NHS does not run “as a creature of magic, called out of the void by the wand of the Minister for Health”. Treat the staff better, and patients will be treated better too.
Margaret McCartney is the author of The State of Medicine – keeping the promise of the NHS (Pinter and Martin)
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