Tag Archives: junior doctors

“Too big to talk about”: Organisational momentum and its paralytic wake

David Zigmond was a small practice GP in south London 1977-2016. You can
read Obituary for St James Church Surgery here.

Corporatism often enlarges and entrenches itself by increasing demands for compliance. Eventually though, unchecked, this will sicken any organisation. Such is now evidently ailing our NHS. A brief glimpse from a small conference provides a sample.

November 2016, London. A small conference of (mostly junior) doctors. The brief: to better survive the increasing stresses of their work. They are being mentored, guided, enabled and reassured by evidently concerned and sympathetic senior clinicians and cohort managers.

Supportive, ventilatory and distracting strategies are suggested: these may palliate, encourage and help endurance.

Discussion turns to appraisals: how tiring, gruelling, dispiriting and stressful they are.

Discussion turns to appraisals: how tiring, gruelling, dispiriting and stressful they are. An older patrician-clinician, Dr O, is able to reassure with statesmanlike knowledge and know-how. Yes, appraisals are an unpleasant, inordinate and major stress for many doctors, Dr O agrees. But he can personally help with this: he knows how the system operates, and who operates it: Dr X, for example. Dr X is very senior in the appraisal hierarchy and wants to be helpful to our many needlessly and haplessly struggling doctors. He can pass on many tricks, feints and shortcuts to neutralise the formidable administrative obstacles and find easier ways to demonstrate the compliance now essential for professional survival. Yes, Dr O continued, these are testing and perilous times but there are those – like Dr X – who will provide sanctuary, ‘a safe house’, help with ersatz documentation. The important thing is that we find ways to tender what we must: to survive.

As I listen to these exchanges I recall heroic stories from World War II: of resistance movements stealthily sheltering, then smuggling to safety, downed allied airmen; of Oscar Schindler duplicitly providing false documentation and work to protect those otherwise doomed. Dr X seemed, to me, like Schindler and Dr O his discrete emissary.

All these efforts, albeit unintentionally, perpetuate a bad and destructive system.

I admired all these caring and protective seniors and the responsibility they showed for the welfare and survival of their juniors. Yet I was doubtful of the larger benefit that would come from these sincere and substantial efforts: to help these tired and craven doctors to pass muster, comply to regulations they experience as draconian, and then survive-by-adaptation with the mandatory documentation. All these efforts, albeit unintentionally, perpetuate a bad and destructive system. Adaptation via obedience can easily turn to collusion.

I attempted, with respectful diplomacy, to say this. I summarised briefly: “I really like the comforting care, support and healing that’s being offered between you. But something much bigger is being ignored: the unsustainable, toxic and oppressive environment we all have to work in. These forces overwhelm and fatally undertow all our attempts to mitigate or repair…”

I had wanted to offer a brief profile of the component-agents of our pathogenic healthcare culture: how the 4Cs – commercialisation, commodification, corporatisation and computerisation – are driving out the human and vocational heart of our work; how our erstwhile (mostly) humanly gratified professional ‘families’ are displaced by managerially driven and depersonalised systems of ‘factories’; how our health services’ administrative devices all drive the larger system that is so ailing and alienating us. The entire Internal Market, Commissioning and Inspection cultures, in their many guises, all contribute: autarkic NHS Trusts, financially-based competitive commissioning; burgeoning performance-related targets with their necessary machinery for monitoring, data, negotiation and penalties; the resulting, ever-increasing need for compliance, surveillance, policing, documentation and (to mop up any surviving outliers) strictly regulated professional appraisal and validation …

But the chairperson arrested the beginning of this flow. She judged it well beyond the scope of this meeting: how may clinicians now best survive?

***

During a short break a veteran manager approaches me. “I know what you want to say. Almost everyone here would agree with you. But there’s nothing we can do about these things: they are far too big for us to influence them”, she says with fraternal commiseration. “In any case, this is not the right forum”, she adds with cautioning advice.

“Well, there never is a ‘right forum’ for discussion of these crucial things now. This recurrent exclusion is not accidental. It is the tip of a systemic iceberg: it tells us much about the size and nature of our problems. Paradoxically, our lack of open discussion indicates why we must talk candidly. And if not now, when?”, I replied.

The manager seems attentive to this but says nothing. She meets my gaze and offers me a brief smile. To me this seemed unjoyfully complex: contrition, appeasement, fear, alliance, apology, irony and respectful pity. I smiled back, wondering what she saw.

She turned to join Dr O. They re-entered the conference room.

—–0—–

Interested? Many articles exploring similar themes are available via David Zigmond’s home page on www.marco-learningsystems.com

 

Junior doctors’ dispute – learning from previous experience

The First Cut Author photo 2Peter Sykes is a retired surgeon and author. His latest light hearted novel, entitled ‘First do no harm’ is set against the industrial action that beset the NHS in the 1970s. His website is www.petersykes.org.

Recently junior doctors voted overwhelmingly in favour of industrial action. It is a situation that they will not have encountered previously, indeed one that many will wish they didn’t have to face. They have many factors to consider when, as individuals, they decide just how militant they are prepared to be. No doubt they will weigh the pros and cons carefully. They may be helped in coming to their decision by considering the lessons learned during the last major dispute with the Government when, as now, junior doctors took industrial action.

In the 1970s, a situation arose that was remarkably similar to that at present. The juniors were negotiating with a Government whose main priority was to reduce public spending because of a burgeoning national debt. Harold Wilson and Denis Healey, Prime Minister and Chancellor respectively, were in the embarrassing situation of having to go ‘cap in hand’ to the International Monetary Fund for a loan to keep the country afloat. A strict wages policy was in place. In the weeks before the ballot, as now, there was relatively little coverage of the dispute in the press though the general public were thought to be broadly sympathetic to the juniors’ plight. Protest marches had been held and representations made to the Minister of Health, Barbara Castle but the Government remained unyielding and a ‘stand-off’ resulted. The mood was one of frustration and anger that genuine concerns were not being heard. There were strident calls in some quarters for a complete withdrawal of labour to force the Government to capitulate. A ballot of junior hospital doctors (JHDs) was arranged.

The ballot paper asked a number of different questions amongst them ‘Are you personally prepared to engage in industrial action and sustain this until the government provides extra money?’ Meetings of juniors were held up and down the country and there was a lively debate in the correspondence pages of medical journals. Some doctors were represented by the British Medical Association, others by the Medical Practitioners Union but a significant number had joined the more recently formed Junior Hospital Doctors Association which was significantly more militant. It rapidly became apparent that many doctors held extremely strong (though widely differing) views on the way forward and the advice they received from the three representative bodies varied enormously.

In deciding how to vote, juniors had many uncertainties to consider. Would it bring doctor into conflict with doctor; some in favour of action, others against? In fact it did; indeed before the result of the ballot was known, a vote of no confidence was passed in the Chair and Executive of the BMA’s negotiating group who were forced to resign from office.

What form should the industrial action take; would some doctors be willing, others unwilling to break the Hippocratic Oath? Who should decide on the form of action? A few spoke of complete withdrawal of labour; others argued that there should be no disruption to the service at all. As it transpired, it was left to individuals to decide and in practice, action was patchy. No one actually ‘went on strike’ and withdrew their labour completely. Some declined to take any action at all, others reduced their hours to 40 per week. Since the average number of hours worked was approximately 80, this had a profound effect and where this policy was implemented, all elective work ceased.

Then there was the question of patient safety; what safeguards would be put in place and who would monitor the situation? In the days before clinical governance, this was left to the conscience of the junior doctors. In the event, there were no reports of disruption to the care of accident and emergency patients.

A major concern was that doctors would damage their career prospects by taking action against the wishes of consultants, some of whom were keen to remind their staff of the hours they had worked when they were juniors! At this time, many consultants were refusing to sign the ‘overtime claims forms’ to sanction payment for work undertaken even though the juniors had a contractual right to such payments. This became a major issue between the juniors and the government who believed that the number of hours of overtime claimed, represented the amount of overtime worked.

A further complication was the major disagreement amongst the juniors as to whether the dispute was about pay or about the principles embodied in the proposed new contract. Is the present dispute principally about pay or is it about safe medical practice? The vote in favour of industrial action, published in November 1975, was 7355 to 5336 (the nature of the action was undefined).

When industrial action began, many failed to anticipate the close examination the press then gave to the junior’s pay and working conditions. This was a time of national financial crisis and support was not universal; some considered that everyone should make sacrifices to help the country through its economic difficulties. Similarly, they were unprepared for the criticism that resulted when patients suffered – as they inevitably did. In 1975, the number of patients treated in hospital was 4% lower than in 1974. The number of patients waiting for admission rose by 12% to the highest level since the NHS began and out-patient attendances were down by 7%. The reputation of the junior doctors was tarnished.

In that previous dispute, there had been no prior agreement of exactly what the government would be required to concede for the industrial action to be withdrawn. In fact, action was discontinued when a contract based on standard pay for a 40 hour week was agreed and an understanding reached that the rate of overtime pay should be determined by an independent body; the juniors therefore returning to normal working before they knew what the financial settlement would be. It was also agreed that the department of Health and the BMA would work jointly to reduce JHD’s excessive hours.

There are lessons to be learned from the JHD’s previous dispute with the Government and it would be wise to heed them. It is hoped that the Department of Health and the junior doctors will resume constructive dialogue so that industrial action, with the inevitable harm that will cause to patients, may be avoided.

Sources

Archives of the British Medical Association
Archives of the Royal College of Nursing
Archives of Confederation of Health Service Employees
Hansard
‘The Castle Diaries 1964 – 1976’ Barbara Castle
‘Fighting all the way’ Barbara Castle
‘The Red Queen’ Authorised biography of Barbara Castle. Anne Perkins
‘The Junior Doctors Pay Dispute 1975 – 1976 Susan Treloar
‘A history of the Royal College of Nursing 1916 – 1990’ Susan McGann, Anne Crowther and Rona Dougall
Lord David Owen Personal Communication