Cheap, undervalued, expendable: junior doctors in 2017?BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3651 (Published 31 July 2017) Cite this as: BMJ 2017;358:j3651
All rapid responses
It is self evident from all the evidence on how the NHS treats the juniors that they don't appear to matter. As it happens this is also true for their seniors. Consutants and GPs who used to be the glue that held the NHS together now find that they are only listened to by their patients.The consultants are no longer in the position that they were when the medical firm still existed and the juniors were an essential part of this family-like structure and were looked after accordingly.
In my book 'The Tyranny of a System - The NHS', I provide some of the historical explanations for the dysfunctional and impersonal mess that the NHS has got itself into.
My solution to restoring the NHS to a health service where people matter is to focus on its basics and which haven't altered -- that is, the patient coming to see a doctor for help.
Years ago what happened in the NHS was not dominated by the management system that we now have. Doctors were listened to. This should still be the case given their selection, training, experience and the fact that they are actually dealing with the patients. Also in those days those working in the NHS from consultants to ward cleaners mattered as individuals and were able to work together without all the rules and regulations that now get in the way of common sense.
The current power of management is to do with the fact that having the final say about the use of funding dictates what happens. My proposal is that the money should flow from what arises out of the doctor-patient encounter and be seen to do so. At that point the doctor takes on the responsibility of the care of that patient. Discharging that responsibility has to be fully supported by the hospital. The details of how that is to be carried out and funded needs medical supervision.
Competing interests: No competing interests
Thank you to Doctor Clarke for (once again) raising the profile of poor morale amongst Junior Doctors.
I would like to raise the topic of incorrect pay, as a factor which over the years has had significant impact upon my morale. Time and time again my pay has been incorrect, frequently as a result of rotating hospital, always within the same deanery.
I have been
- had my pension deductions stopped without consultation
- had arrears from the above deducted from my wages without my permission
Colleagues suffer the same problems but we all just shrug, along with payroll and HR. Again, its 'just the way it is'.
Would others join me in demanding that we get paid the correct amount in a timely manner?
Competing interests: No competing interests
It is sad that one year after a high profile dispute brought commitments from all involved to tackle rock-bottom junior doctor morale, the unacceptable behaviour of many NHS employers is still the norm. This includes, but is not limited to:
- little or no advance notice of rotas, hours and pay;
- sometimes even a change in job location with very little notice;
- an expectation that trainees will travel to jobs a long distance apart, with a refusal to provide or support transport;
- a refusal to sanction leave in advance of the August handover, even for e.g. weddings in August;
- pressure on doctors to cover and/or arrange cover for rota gaps, including those due to their own ill health;
- a reluctance to allow trainees to take compassionate leave;
- lack of hot food and rest facilities at night;
- expectation of work being done out of hours for free, including mandatory induction and other training.
This is not a failure to achieve best practice. This is a failure to honour commitments made under the new junior doctors contract (1), and indeed under previous arrangements brokered between Deaneries, Trusts and trainees (represented by Medical Education England, NHS Employers and the BMA respectively) (2).
It is also a failure to do what would be considered the bare minimum in any other industry. I should know, having worked for six years as a management consultant before studying medicine as a graduate. My employers then recognised that their staff were by far their most important asset, a similar situation to healthcare, and treated us accordingly. The crucial difference however is that, unlike professional services firms, the NHS does not have to compete with other employers for talent. With only work for the NHS recognised as training, NHS trusts are a de facto monopoly employer, at least for anyone seeking career progression. Perhaps this has led to complacency.
Morale is now so low that, despite the 5+ years of undergraduate education and associated student debt, junior doctors are leaving the NHS in their droves. This includes half of those just two years after graduating (3), with a subsequent inability to fill specialty training posts across the board (4). Worse, it is leading to burnout, with multiple surveys reporting rates of mental health problems in junior doctors of 60% and over (5) (6). Trainees can no longer be taken for granted.
The NHS is cost constrained, but addressing the grievances above would cost nothing. To do so requires that the CEOs of Health Education England and NHS Trusts must make employee welfare their top priority, much as professional services firms do. If not, they will one day find they don't have enough junior doctors left to run their much-vaunted services.
Dr Hugo Farne
Specialist Registrar in Respiratory Medicine, London
1. Junior doctors terms and conditions of service March 2017. NHS Employers. 31/03/2017.
2. Code of Practice - Provision of Information for Postgraduate Medical Training. BMA, Department for Business Innovation & Skills, NHS Employers, Medical Education England. 12/09/2010.
3. The Foundation Programme Career Destination Report 2016. December 2016.
4. Specialty recruitment: round 1 - acceptance and fill rate. Health Education England, last updated 4 July 2017.
5. Cohen D, Winstanley SJ, Greene G. Understanding doctors' attitudes towards self-disclosure of mental ill health. Occup Med (Lond). 2016 Jul;66(5):383-9.
6. 2017 Survey of Anaesthetists in Training, as reported in RCoA: President's News, February 2017.
Competing interests: I am a junior doctor.