Increasing exploitation of NHS doctors. Did doctors themselves create this beast?

NHS junior doctors are currently in dispute with the Department of Health over plans to reduce unsocial hours pay while increasing weekend working.  Questions about how the necessary increase in staffing levels will be met have been asked, but as yet remain unanswered.⁽¹⁾  Where did the Department of Health’s expectation that doctors would accept these conditions come from?

I believe exploitation of NHS doctors is growing due to a positive feedback loop that the subculture of the medical profession is partly responsible for.  When I first worked for the NHS as a nursing assistant, house officers were provided with free hospital accommodation.  This was removed as the European Working Time Directive (EWTD) was in theory applied to doctors.⁽²⁾  In reality with respect to junior doctors the EWTD is a work of fiction due to inadequate staffing levels.⁽³⁾   When I started one of my junior doctor jobs I was made to sign printed statements promising that I would not work any extra hours without prior written consultant approval and that I would report my working hours accurately when monitored.  This was contrary to specific advice given during induction at the same Trust by a prominent character who said “Don’t be a clock-watcher.” Working within rostered hours was not feasible, partly because consultant ward rounds often happened after juniors should have gone home.  

The first time I produced a Consultant Approval Form for extra hours I was looked upon with disbelief.  None of my senior house officers (SHOs) or registrars had ever seen the form before.  One SHO told me I would get into trouble for raising the issue of working extra time. The Consultant however, who appeared to have never seen the form before either signed it without question.  Nevertheless, I was discouraged from using the Consultant Approval Form again due to none of the clinical staff being familiar with it, my SHO’s prior warning and the fact consultants were often not easily accessible when we had to stay late.  Later I made the grave error of honestly reporting my working hours during monitoring.  I was taken to one side by a senior figure and warned that if I did this again other senior figures would notice me and I would be penalised.  Also, apparently my actions were unethical because they could lead to the Trust being fined vast sums of money!  I felt threatened and this troubled me, disturbing my sleep for a couple of weeks.  I asked a registrar for advice on how to resolve the inner conflict between my contractual agreement with the Trust to be honest and the reality of doctors’ working behaviour.  The registrar gave me the following simple workable analysis:

1. The Trust only wants us to work a specific number of hours.
2. We know this is not safe or good for our patients, so we stay late.
3. The Trust does not want us to work these extra hours, so we do it by choice in our own time.
4. Because we are doing it voluntarily in our own time it is not classed as work, so we should not report it in our hours monitoring.

So there we have it.  Doctors have been guilt-tripping themselves into working unpaid hours and covering up NHS staff-shortages for years.  Many of my friends had it worse.  One foundation doctor was told off by a registrar for completing medical records documentation during official working hours!  I previously believed that conditions for junior doctors were historically worse, but to my surprise the consultant who had signed my Consultant Approval Form for extra hours told me things are worse now than when he was a trainee, due to increased patient through-put with most of the patients occupying hospital beds now being clinically unwell rather than recovering.  This was illustrated well by Dr Henry Goodall describing how he only used to get “at least two to three phone calls from nursing staff” per night-shift as house officer.⁽⁴⁾  Today, two or three bleeps per hour would be considered a quiet night.  Even today some are questioning whether doctors should be entitled to pay for all the hours they work or whether surgeons should be able to opt out of EWTD.^{(5, 6)}  Who is benefitting from this work ethic that is perpetuated within the medical profession itself?  The Department of Health continues to expect junior doctors to make increasing sacrifices of their personal and family lives without thoughts of compensation.  Patients are unlikely to benefit from decreased staffing levels though senior NHS managers seem to be rewarded.^{(7, 8)}

The exploitation of doctors cannot continue to increase indefinitely.  The continued acceptance of worsening working conditions for doctors depended in part on a system of bullying within the medical profession that starts in medical schools.^{(9, 10)}  By simultaneously engaging in conflict with junior doctors, consultants and general practitioners, the Department of Health may have made the critical mistake of uniting all doctors and breaking their will to uphold that bullying system.  Perhaps now is the time for fearless truth-telling, to identify staffing problems that have long needed fixing.

References:

1. Wollaston S. our hours were even worse & these kind of feelings were widely expressed then too but new contract aims to shorten hours. [updated 2016 Jan 11; cited 2016 Feb 4] Available from: https://twitter.com/VenthanMailoo/status/686520637007998976
2. Gajendragadkar P, Khoyratty S. Junior doctors’ accommodation—more than just the money. [updated 2009 Sept 16; cited 2016 Feb 4] Available from: http://careers.bmj.com/careers/advice/view-article.html?id=20000374
3. Mailoo V. Is our profession in need of occupational therapy? DOI: 10.3399/bjgp14X680173 
4. Goodall H. Current generation of doctors work less hard for more money and fewer hours’  [updated 2016 Jan 13; cited 2016 Feb 4] Available from: http://www.itv.com/news/2016-01-12/current-generation-of-doctors-work-less-hard-for-more-money-and-fewer-hours/
5. Winwright P. [updated 2016 Feb 4; cited 2016 Feb 4] Available from: https://www.facebook.com/groups/1703752843188523/permalink/1748681712028969/
6. Chand M. Should UK trainee surgeons be able to opt out of EWTD? [updated 2016 Feb 2; cited 2016 Feb 4] Available from: https://twitter.com/ManishChandSurg/status/694579643110801408
7. Campbell D. Hospitals told to cut staff amid spiralling NHS cash crisis. [updated 2016 Jan 29; cited 2016 Feb 4] Available from: http://www.theguardian.com/society/2016/jan/29/hospitals-told-cut-staff-nhs-cash-crisis
8. Donnelly L. NHS hospital bosses given pay rises worth more than a nurse's annual salary. [updated 2016 Jan 2; cited 2016 Feb 4] Available from: http://www.telegraph.co.uk/news/health/12077917/NHS-hospital-bosses-given-pay-rises-worth-more-than-a-nurses-annual-salary.html
9. Srivastava R. I wasn't surprised by Four Corners. Bullying in medicine is as old as the profession. [updated 2015 May 26; cited 2016 Feb 4] Available from: http://www.theguardian.com/commentisfree/2015/may/26/i-wasnt-surprised-by-four-corners-bullying-in-medicine-is-as-old-as-the-profession
10. Curtis P. Medical students complain of bullying. [updated 2005 May 4 cited 2016 Feb 4] Available from: http://www.theguardian.com/education/2005/may/04/highereducation.science