Letter to MP - regarding Junior Doctor industrial action 2023

 

It’s fitting that the first time I use this blog in 5 years is to talk about industrial action for doctors seeing as the 2016 strikes was the event this blog was at its most busy. 

I thought I would share the letter I’ve sent in case anybody wanted to use it for their own letter (with their own MP and constituency). We get more done with more people doing something! 

https://www.writetothem.com/

Dear Andrea Leadsom,

I write with grave concern about the current failure in government negotiations over fair pay for junior doctors and the ongoing industrial action this causes.

As a current hospital consultant we were able to cover the first set of strikes, albeit with significant disruption to service. Prolonged strikes not only underline the importance of junior doctors to the provision of healthcare in this country, but significantly impair our ability to provide the care our patients deserve. 

After 12 years of eroded pay and the trauma of the pandemic, morale in the health service is at its lowest in my career. Junior doctors are voting with their feet and feel let down by the government on multiple fronts from pay to conditions to training.  

I fully back my colleagues fight for fair pay and I think it is imperative that the DHSC come back with credible negotiations with the JDC. 

I urge you to express these patient safety concerns to your ministerial colleague in the Department for Health and Social Care to help safeguard the health system for the people of South Northants. 

Yours sincerely,

Dr Scott Mabbutt 

My First Extraordinary Council Meeting, Or: (How I Learnt to Stop Worrying and Love Losing Arguments)

You may think that spending your Monday night at a Council meeting about local government reorganisation isn't a great topic for a blog post, but here it is. Last night was an "Extraordinary Meeting" - which I take to mean it was unscheduled as the motion at hand was too important or time dependent to wait until the next meeting. I don't have any particular insider information, so this is pretty much only my take on what I thought happened.

The background to the meeting is that Northamptonshire is currently run by a two tier council system where the County Council looks after some functions like schools, roads and libraries and there are 7 district councils which have a smaller area and cover things like planning, waste collection and licensing. The County Council is currently in a dire financial situation, being unable to pass a decent budget and having central government oversight in an effort to re-organise and turn things around.

The motion for the extraordinary meeting was about how the new council(s) should be formed. There seems to be no opposition to the idea that whatever replaces the current model will be unitary based i.e. - all local government functions for that area will be provided by the same council. There is however different ideas on how many and what the boundaries should be. A report by Deloitte proposed 4 options:  A single Unitary, 2 unitaries (West & North), 2 unitaries (Northampton & Shire) or 3 Unitaries (West, North and Northampton).

The motion was proposed by the leaders of the 3 main parties in Northampton, which suggests cross party support. It backed a 3 Unitary model with a separate Unitary council for Northampton with extended boundaries to encompass new developments. It called for a public consultation and an exercise to make the case for a Northampton Unitary.

The 2018 central government inspection of the county council was so critical it said that the status quo had to change and "Northamptonshire County Council (NCC) has failed to comply with its duty under the Local Government Act 1999 (as amended) to provide best value in the delivery of its services". It favoured establishment of a two unitary model with Daventry, South Northants and Northampton in one and Wellingborough, Kettering, Corby & East Northants in another.

I attended as a member of the public and spoke in favour of the motion. I had put forward the idea that whatever council emerged from the ashes of the old one would use the proportional voting system, STV  to provide a council that better reflected the views of the electorate it was to represent. Despite it being my personal favourite drum to beat it wasn't really part of the ongoing Unitary debate. There was a rigorous debate after the public speakers about the motion and compelling arguments made on both sides.

The first argument in favour of the motion was based on the fact that considering what was being proposed was billed as "the most important decision in the town's recent history" the townspeople should at least be consulted on what they thought was best and informed of the potential options. I don't think that that is a particularly big ask.

Secondly, the demographics of Northampton is so different to that of its surrounding area it makes sense to administer services that are bespoke for that population. Whilst most of Northants is rural, there are areas of town which are densely populated and deprived and would benefit from services which are tailored for that. Having to provide contracts that need to provide for two different population priorities can result in nobody being happy. In an effort to balance the books (perhaps after years of underfunding) will it fall on Town assets to be sold to pay for the shortfall?

Thirdly, I wonder what the rural areas think of having to be part of a council where >60% of the councillors will represent urban areas and priorities. Will their priorities be drowned out by the Tyranny of the majority? Will they want to subsidise more resource intense urban households who, I'm told, cost more per head?

Lastly, and which, unfortunately in my opinion, was the argument most posited by those in favour of the motion is a philosophical reason; somewhat akin to some of the arguments made in the Brexit referendum. Who are we? What is our shared identity? What do we call ourselves? We're Northamptonians, not West Northamptonshirians so should be in charge of our own destiny. Localism is about having decisions made as close to the population being affected as possible and would an large arbitrary boundary, drawn for fiscal reasons, give us a sense of shared vision? The reason I feel this is the weakest of the 4 main arguments is I think most people don't care who collects their bins and derive their local and civic pride by other means. Sporting teams or community groups for example.

The arguments against the motion were also interesting and worth looking at. In my mind the most compelling argument against wasn't given by a councillor, but by a fellow public speaker. Namely that as the largest population centre in the county we had responsibility to provide opportunities and services within the town for those in the surrounding areas as we are linked by geography and many people in rural areas visit or work in the town and may have shared interests.

Another public speaker pointed  out that with a larger unitary, projects and services could be purchased at scale with the ability to get better deals due to bigger purchasing power. They also pointed out that a wider area would mean joint infrastructure could be planned more fairly in a more joined up manner, avoiding a situation where one rural council builds houses on the edge of town and then don't have to deal with the services as much.

Of course the biggest reason to vote against the motion was financial.

It was true that the 3 unitary option, whilst being fiscally viable, would not clear the black hole in the budget as quickly as the other models. It would need it's own separate executive structure and employees and these would cost money. The number £750/household/year increase in council tax was put forward by the councillor in charge of finances, as the cost of the 3 unitary model.

So, despite having helped propose the motion in the first place, it fell, by the votes of the majority Conservative administration. One could argue they changed their minds by the robust evidence produced, or that their party was also in charge of the government department which backed 2 unitaries. The cynics in the audience suggested that a larger semi rural council will more likely deliver a Conservative administration due to the location of the safe seats. Whatever the reason, all 22 councillors voted against the motion, which essentially made the meeting pointless - there will be no public consultation and we'll move to 2 unitaries in 2020.

It was a very interesting experience and it showed a political party machine in action. The only message you will hear in chorus from Conservative Councillors today is "It'll cost £750 a year for your idea". It's painted as the sensible and pragmatic way forward and it is an extremely persuasive message. The reason I think it is disingenuous is because it has no comparator.  It's just a number, a big one, and that is definitely what it will cost. There's no mention of the cost of the remaining proposal. With 8 years of cuts to local government funding, with nationally low council tax bills, with essentially a bankrupt council, surely council tax will HAVE to up under any circumstance. Are they saying under their proposal council tax won't go up at all?

I would like to know how this £750 number was derived, what the comparative number is for the 2 unitary solution and is there any way the books can be balanced without a council tax rise? I smell an FOI request.

*exhales* There is the rather long story of my first council meeting. I learnt a lot and saw a lot, but mostly I re-learnt a lesson I should know by now. Money Talks.

Improving Westerosi Maternity Services - Every Mummer Counts

The long awaited follow up to my argument in favour of improved Trauma Services is looking at the need for better maternity care in Westeros.


Women in Westeros get a bad deal and is this most evident in it's shocking maternal mortality rates. Whilst definitive statistics are difficult to come by there is a rich stock of qualitative data from documentary series "Game of Thrones". It shows that childbirth is dangerous and pregnancy gives no reprieve from the violence of the world.

The first major problem is access to basic medical care for even the most highborn of women. Arguably the root of Robert's Rebellion was the fact Lyanna Stark, though surrounded by willing servants in a prestigious tower died from a post partum haemorrhage. Adequate access to uterotonic medication and availability of those suitably trained in repair of perineal trauma may have averted such a tumultuous period in Westerosi history.

It is no better across the Narrow Sea where perinatal mortality is also worryingly high. Added to this we have proof of non evidence based blood magic from unlicensed Maeges have been responsible for the stillbirth of Daenerys Targaryen's child. It is important that any new process or therapy is rigorously peer approved and based on sound scientific evidence and the risks of alternative therapies are communicated to women and consent gained accordingly.

The stories here are just the affluent tip of the iceberg. There will be thousands of stories of less privileged women dying in poverty due to lack of access to midwifery care and sanitation.

That's not to say there aren't successes. There is documentation of multiple births north of the wall at Craster's Keep and indeed the Queen on the Iron Throne has successfully delivered 3 children under dubious lineage. Consanguinity as a protective factor could be an interesting topic for further research?

Maternal Mortality statistics also contain deaths from indirect causes, which commonly seems to be deaths from domestic violence. This includes the recent death of Walda Bolton and her newborn son. Having successfully traversed a high risk pregnancy with a raised BMI, care in post partum time should include a thorough domestic violence risk assessment which would have surely have picked up on the dangerous individuals in her household. Without robust systems and social services in place these vulnerable people were let down by the crown.

Calls are then made for access to those with formal training in childbirth and maternity care. This surely must fall into the remit of Maesters who are ideally placed to lead maternity care. They have anatomical and pharmaceutical knowledge to make a real difference in the delivery of maternity care. However they have their own issues before being made part of the maternal health team. Being very secretive with their knowledge is not the right way to go about healthcare innovation and they would need to embrace a more open non-blame culture in improving outcomes. They would also need to evaluate their own practices against current trends to ensure that Maesterising birth doesn't lead to poor outcomes and a loss of maternal choice in their birth decision making. Lastly, for too long women's decisions are being taken by men so the archaic bar to women joining the Citadel must be reversed in order to allow women to care for women and be armed with as much up to date information as possible.

There is reason for cautious optimism with a woman on the Iron Throne women at the head of many powerful families currently, the time is right to allow the establishment of midwifery as a right for every pregnant woman in Westeros. Couple that with access to evidenced based maester led high risk care. What good is war if there is nobody to carry on the family lineage? Allocation of recently acquired gold would go some way to show the people that women's health is taken seriously by the current administration.

Election Dissection: This time it's Personal

2017 General Election represented my first foray into national electoral politics. I had stood as a paper council candidate for the Green Party in the 2017 local elections but this was obviously a much bigger deal. I have written about how the Green Party did nationally here but also wanted to look at my own performance and plans for the future.

When people ask how on earth did I get into this, there was no magic moment, just a series of small events which lead to standing for Parliament in my home town. In 2015 when I moved back to Northampton, I had voted for Green Party at the 2 previous elections and decided in that summer I wanted to get more involved with local politics, seeing as my knees were no longer up to Sunday league football. So I joined the Green Party and attended the September 2015 Party Conference, which was fantastic, but due to work, didn't manage to make it to any meetings that year. Then in 2016 I attended an event protesting against an incinerator being built in the town with support from Northants Green Party. It was here I met local activists and resolved to attend meetings to see where I could help.

After a couple of meetings we had our AGM where the chance to run social media and website came up, which I took up in September 2016. We then organised attending events and marches for the NHS, Pro-Democracy and Anti-War causes as well as local air quality testing. I was asked to be a paper candidate in the 2017 local elections, which just provided a chance to vote Green in my area. There was no campaign, although I did help out with the campaign for our target ward in Northampton. Then the snap election was called, and despite having selected 7 candidates back in 2016 on the hunch a snap election would be called after Brexit, we had 3 vacancies for General Election Candidates in Northamptonshire. I expressed an interest, made a short speech at our selection meeting and there I was!

So, what happened next?

Election was called on 18th April, I was selected on 2nd May, attended local election count on 5th May and submitted my application to local electoral services on May 10th, having not managed to agree any Progressive Alliance locally. I had put up the £500 deposit from combined party, crowdfunded and personal funds there was not much time or money to run a large campaign. This not being helped by continuing to work my full hospital commitments.

I set up a Facebook campaign page and churned out tweets, videos and updates. I answered hundreds of lobbying emails and pledges to support various causes. I went on as much media as I could manage, radio, TV, newspaper hustings. I visited my old school and supported national campaigns. I posted about 5000 leaflets with the help of a number of local volunteers, who I am massively grateful to.

Now, regular readers of my blog will know that if somebody were to ask me what my biggest weakness was, I'd say "Job interviews". I'd just signed up for a public job interview which will last 4 weeks. So, way to face up to them fears!

I think that I honestly put about as much into the campaign as I could. I'm not happy with the outcome and some of that is due to a national trend of a reduction in Green vote and rise of an actual Left wing Labour party. Part of it I think was due to my limitations as a candidate, not only financially but with free time and getting my message out. I was aware that we needed a distinct message from the Labour Party but unfortunately too many of my answers at hustings began "I agree with Kevin...". My family and friends were a great help but I didn't want to put too much on them in terms of door knocking and leafleting so much of that I took on myself. We didn't have an army of door knockers or reams of canvassing data. I didn't feel I had the money to put out a full free post leaflet to every constituent and unfortunately did hear murmurs that some people didn't know a Green candidate was standing. I was also a bit miffed that media outlets like ITV news would interview the other 4 candidates but not me, especially as in terms of votes, 3 of the 5 of us were fairly close.

I know you should never watch yourself give media performances but I looked hesitant and nervous about putting a point across which was usually a good point! The hesitancy is me though. It's who I am. I run everything I think through a filter as I'm worried what people would think when it comes out. When I'm tired or stressed sometimes the filter doesn't work! At least I can say that all of my media performances were authentic and not somebody else. I think I got better as I got more into it, but with only 4 weeks there wasn't much time to warm up.

So, what happens next?

Firstly, it's my annual appraisal later this month (ARCP) which decides if I've progressed enough this year as a doctor to be allowed to go onto the next stage of specialist training. There are still some things to tidy up from there and work to be done.

As for the Green Party, we've got a lot of thinking and work to do. It's clear by our vote share that our message wasn't getting out or convincing enough. The Green policies I like the most are the ones we don't share with Labour: Citizen's income, Nuclear Disarmament, Soft Brexit, Proportional Representation and commitment to leaving fossil fuels in the ground. However these weren't what the election was about. Corbyn shut Brexit off as an issue by essentially agreeing with the government and the important issues of the electorate: - Social care, Education and the NHS we didn't offer an alternative to Labour policy.

What I want to do next is figure out how we can do better next time, given our limited human and financial resources. Personally, I enjoyed the whole thing and would thoroughly like to do it again. I just don't like losing so hard. The Green Party target to win policy I think is the way forward. As a local party with maybe 2 dozen active members, for the 2019 local elections, I think instead of running many campaigns in a low power way, perhaps we need to focus our attention in 1 area to get maximum gain. That would mean me volunteering by leafleting and door knocking in one place with ALL the other candidates and members in just one or two wards.

I'd also have to change the type of work. Seeing the 2 main parties campaigning  threw into sharp relief the size our tasks. They proved that you need boots on the ground not only to leaflet but to door knock and get canvassing information. That is something we could be doing all year round, and will try to attend a Green Party canvasser course in the near future. If we have 5% of the activists we need to focus our efforts in a smaller area to make a gain. Even a single council seat in Northamptonshire would be a huge improvement not only for ourselves, but for the voices of locals who see a sea of blue through all the diesel fumes.

We are at our  best when we are local, visible and vocal, which with regards to air quality I think we are. I think we ought to champion this issue across the board for all of our active local measures and direct efforts to getting more air testing data, more time at council meetings and more local support. We could start a "Green Business" group, to promote businesses which have an environmental angle or do something good in the community, which could  hopefully attract business and sponsorship. Every chance to get in local media to show we are doing something, whether that is fitting new air tubes, picking up litter or turning up en masse to cabinet meetings.

Personally, I could get more involved with my hospital and community groups to help with issues we might be facing. My current role as BMA rep it appears that our major issue is parking. Campaigning on something to address this like a park and ride for example could be the way forward. In my own ward, I want to be attending parish council meetings and trying to figure out what is happening with development (or lack thereof) of the St Crispin's Hospital site which has lay derelict for the 2 years I've lived there. I'll be putting these ideas to our post election meeting tomorrow, so I could end up doing a lot of work whilst continuing my O&G training, which as my sole income and life for the last 13 years is no small priority.

I think there is still a future for the Green's, we just have a grab it work harder for it and make each Green activist count double with the work we put in!

Election Dissection

The first general election of 2017 was one where everyone lost.

Theresa May is terminally damaged by arrogantly calling an election on the issue she wanted, Brexit. Whereas the electorate rightly voted about policies, where the Tory manifesto was found wanting. Her leadership proved to be anything but strong and stable, and she's going to limp along with the help of some climate change denying bigots.

Labour lost this election, just not as badly as everyone thought they would. They are over 60 seats short of forming a majority government, despite gaining seats in key marginals. Corbyn may have grown as a leader and won some young voters, but will the legion of no confidence voting MPs suddenly have discovered a love for him? Against all odds Labour appeared to have won some seats, have they got it in them to do it again later this year?

The Liberal Democrat land grab of the remainers didn't bear the fruits first thought and the echo of their Europhile drumbeat will ebb away as Brexit negotiations continue. Even strong remainers like myself, just want to see it done with in a quick and painless a manner as possible. Delaying things will just put on hold the fact that we need to remake our country in a fairer way and sort out our environment and public services.

UKIP may have fell away considerably, but their supporters didn't exclusively flood to the Tories. Again, once Brexit is over what is there for them to campaign on? I imagine they will adopt more right wing, anti-immigration dog whistle politics to differentiate themselves from the Tories.

SNP having hit a zenith last time out, were never going to do that well again. The issue of Scottish independence spooked people into voting Tory in Scotland for the first time in my lifetime. I think they have about hit their mark with vote share and seat number.

As for us, The Green Party didn't do well even by our own measurements. Sure, Caroline Lucas was returned with an increased majority and we got half a million votes nationally. Our aim was 2 MPs which we didn't seem anywhere near getting in our key targets of IoW, Bristol West & Sheffield Central. We also only got half the votes we did last time out. The reasons for this I think are the lurch to the left of the labour party where there was significant crossover with policies we've held for a long time such as scrapping Tuition Fees and renationalising the railways. This meant people who joined the Greens because there wasn't a progressive left wing party around any more felt comfortable to go back to labour. Also a small party with a campaign short on resources and canvassing data was never going to perform as well as during a normal electoral cycle.

We also have an issue with the Progressive Alliance policy. I can see why we do it in that we are a smaller party and would rather have a labour government than a Tory one; but I'd rather have a Green one than a Labour one! We unilaterally stood down in seats as a show of good will hoping others would see it's benefit and it wasn't reciprocated. It won't be reciprocated, that much is clear. Any sign of Labour doing deals with us, overtly or covertly will be seized upon as weakness by the press and or Tories. It seems any co-operation we do is expected across the board.

Personally, the only online grief I received for standing for parliament were from Labour supporters who thought I shouldn't be standing. Not once did they try and tell me about how great their policies were or why we should vote for labour, just "waste your vote on Green" "A green vote is a Tory vote". You win votes by having better policies, not bullying smaller parties into oblivion. We are very different to the Labour party, they've moved their policies towards us, not the other way around. We don't want to fund nuclear war or go ahead with leaving the single market or continue with environmental inertia. I also think, many of our remaining voters wouldn't automatically go to labour. I think many would abstain or spoil if we aren't on the ballot, as many vote Green as they are disillusioned with mainstream electoral politics.

The way I see it, we have 4 options nationally going forward and none of them are perfect. The current half measure hasn't worked, I can't see the status quo happening again where we do all the stepping down and get very little in return. I also wouldn't want to do what a couple of friends of mine in Momentum would like, which is to become the Environmental wing of the labour party and trade our identity and policies in for a few former Greens getting Labour seats.
We could double down on Progressive Alliance, formally support Labour where we don't stand and stand down in 100s of seats. Not only to stop a "split the vote" situation where we lose 100s of deposits but to focus national resource at getting more Green MPs in places they might actually get elected. This might get us another MP and a chance to push proportional representation, but risks alienating Green's nationally. Or we abandon the notion all together, stand wherever we can and show voters that we offer a different vision to all of the mainstream political parties and be proud to do so. This might get us a wider reception but would probably keep our vote share in the low single figures range.

The elephant in the room is the First Past the Post electoral system. It's defenders say it keeps out extremists and provides decisive government. On evidence of the most recent election, it has done neither. The other defence of FPTP is that it maintains a local link to your MP. In the seat I stood in, the address of the new MP on the ballot is 60 miles away. Democracy doesn't work if large quantities of people's vote just don't matter and for 500,000 people we get 1/650th of the voice in parliament. All efforts in cross party co-operation must have proportional representation at it's heart. I'm not sure which way we Greens should turn next with regard to PA, but it needs to have change the entire voting system at it's heart.







The FT have done some excellent graphs about changing demographics and voting trends. I recommend you give it a read!

https://www.ft.com/content/dac3a3b2-4ad7-11e7-919a-1e14ce4af89b?mhq5j=e3

A Difficult Conversation

I didn't make a new year's resolution this year. Mostly because any previous ones I've made, go out the window within a couple of hours. Also, my go to "stop being fat" resolution is already being attempted as I've been on a "healthy eating" kick for 5 months or so already. However if I were to make a resolution, other than blogging more, it would be to spend my free evenings not on social media but reading the increasing pile of books I have accrued over the last few years. The pile ever increases because whilst I buy around a book a month with good intentions, I probably only get through 1 every 2-3 months. There are currently a range of biographies, GoT novels, political polemics and other books building up on my bookshelf. I'm so terrible at keeping up with it that I purchased Paul Mason's "post capitalism" twice as I forgot it was already in my "to read" pile. I guess that illustrates the inherent waste of consumerism he is trying to get at; I don't know, I haven't read it yet!

Anyhow, I started as I meant to go on and picked up Atul Gawande's "Being Mortal". I thought this was a safe place to start as his other book I read "The Checklist  Manifesto" was so good it changed the way I worked in the operating theatre. Going from sighing my way through the WHO checklist to making it a central part of being in theatre. Gawande is one of those people who seems to be able to do anything. An accomplished surgeon, writer, NGO and public health leader. In fact if he played for United he'd be the picture at the bottom of this blog!

Its about how medicine has changed the way we experience ageing and death and the things people around America are doing to try and improve this situation. He tells a story of not wanting to confront a young patient's impending death from lung cancer by using euphemisms, and how difficult it was to actually bring up the subject for the doctor. Instead talking about "putting this issue aside so we can focus on the lung cancer". This resonated so much with my own experience of  these conversations and I had an example where I ended up having a difficult conversation, in a situation you wouldn't normally expect.

The junior doctors usually have the job of clerking in elective patients for day case procedures. Usually it's a quick chat, write up their regular medication and make sure their consent form and blood tests are up to date. This case was unfortunately a young patient with advanced ovarian cancer coming in for an ascitic drain to relieve the discomfort of having fluid build up in her abdomen. Her cancer was incurable and she had tried 2 types of chemotherapy without success already.

I duly went through her medical history and medications, which were surprisingly few for someone so poorly and noticed she was on a statin. A statin is a drug that lowers cholesterol and can help prevent strokes and heart attacks if given to enough people over a long enough time period. The patient told me that they gave her nausea but stuck with a low dose because it was good for her in the long term. This is right, but things had changed since she started on her cancer journey.

The easy thing to do would be chart the statin and get on with things but I asked if she wanted to carry on taking the medication. I struggled to find a way to say "why take a drug that makes you feel ill and won't help you because you'll be dead from your cancer before you get the benefit of the statin" without sounding horrible. So I tried to see what her understanding was about statins, and she seemed clued up and then seemed to stop and then was to the point for me:

"The cancer will get me before a heart attack will, won't it?"

I gave a non-comittal grimace and suggested she could stop it to see if it helped her nausea. She stopped the drug and when she came back a few weeks later for another drainage, she told me she felt slightly better from a nausea point of view. It showed that having difficult conversations are actually be worth it for patients and we as doctors tend to practice with inertia (especially if another doctor started the medications). Helping patients make sensible decisions about preventative medications is a small part to play, but showed tackling these may help in the long run.

So, just like the Checklist Manifesto changed my operating pratice,  it looks like Gawande's next book will change how I practise medicine in patients who are terminally ill.

Oh, and if anyone wants a copy of Paul Mason's Post Capitalism, I have a spare!

The BMA Bop

In August my new trust sent an email asking for candidates to become the hospital's Junior Doctor representative on the BMA local negotiating committee. I sent a very non-committal email back saying I was interested and would like more information. I was fully expecting that in the current climate there would be a deluge of willing volunteers and someone louder and more polished than me could give some soaring oratory to get the post. In the last trust I worked in we had 9 applicants for the post and an election had to be held. I had underestimated the apathy in my current institution.

After 6 weeks nobody had gotten back to me from the BMA so I assumed that they had found someone or hadn't got my email. If a week is a long time in politics, 6 weeks is an age. In this time the BMA had gone from losing a ballot, declaring strike action then cancelling said strike action. It was fair to say I wasn't overly enamoured with them as an organisation for declaring strike action then cancelling it in quick succession. They were entirely right to call action if 58% had not accepted the contract, but where the 4 x 5 days figure was plucked from and why it was called off I'll never know.

It was therefore to my immense surprise when I receive an email saying I had been voted in as JD rep at their meeting (which I hadn't attended and didn't know about) as nobody else had come forward. So in late September I was made junior LNC rep and had to hastily organise a picket and ensure departments could cover their work. I figured the situation must still be salvageable at a national level (despite only hearing about press releases through BBC) so I decided to give it my best shot.

I started by trying to gauge reaction to the idea of 5 days of strike action, in order to represent the views of local members. If you look back to my previous post I had originally planned not to strike. This was due to the financial implications of losing potentially 4 weeks pay as well as my training record; Health Education England had sent us an email reminding us we may fail our training appraisal if we missed more than 2 weeks of work. I sent an email out to all junior doctors and spoke to the juniors in my department of O&G as well as nearby specialities like paediatrics and anaesthesia. I also tried to get a view of the FY1s at their teaching sessions. From my conversations I got the impression that nobody really wanted to strike for 5 days even those who had voted the contract offer down. From my email to 150 doctors, I received a solitary reply, echoing these sentiments.

I had gone from someone who was not planning to strike and wavering on whether to keep my BMA subscription going to somebody visibly representing the BMA within the hospital and trying to organise a picket. Then it got very difficult for me. The job lot of strikes was cancelled (again I found out via BBC) without anything in it's place and without an explanation. I enquired higher up and advised that a JDC meeting a month away would clear everything up. At this point O&G registrars were being started  on the new contract. It appeared there was no going back. But hey, at least we got the now infamous stickers in the post to proudly wear whilst nothing happened.

The stickers that launched no ships at all

So whilst the JDC were navel gazing I had to face my colleagues at the junior doctor forum and tell them that I knew nothing about the cancelled strike action and no plans were in place. I was rightly given some upset words from my colleagues. I waited for news of our next move, my proud sticker starting to curl on my lapel. The next meeting of the JDC only served to lose another chair. I waited some more and on radio 4's today show Dr Porter effectively ended our dispute with the government. With the new chair of JDC assuring us we are still in dispute and are back at the negotiating table, you can forgive me for not holding my breath.

In the absence of any guidance I made a decision at this point to work with the trust to ensure that they had all the statutory systems in place required for the contract to be imposed, and hold them to account if they didn't. It is to be said that the trusts are innocent bystanders in this and with pay protection actually stand to lose a fair amount of money over the next few years because of the new contract. Here is where I feel I've actually been useful as a BMA representative.

Along with the very helpful Industrial Relations Officers I have been involved locally with almost every aspect of the new contract. I've helped to appoint a guardian of safe working, I've tested and decided on which exception reporting software is to be used. I've looked at FY1 rotas to ensure they are compliant. I've broken down the contract and it's minutiae with our first cohort to be imposed upon to reassure them that nobody is getting a pay cut or a change in their rota. I've reviewed the equality impact assessment from the trust - interestingly it being inherently unfair on LTFT workers was not mentioned.  We've agreed with the trust to postpone most doctors going onto the new contract until August 2017.

My hope is that the contract is an unworkable disaster. The exception reporting relies heavily on educational supervisors to discuss and change work schedules as needed, which is all potentially a lot of new work. They will receive no extra time or money for this. Trusts may well find educational supervisors sign off exception reports as one-offs and give the payments to the doctors as it is the easiest way to solve the problem. Once the money starts accruing we might see something positive happen in terms of working conditions. I would therefore recommend any junior doctor reading this to fill out exception reports for EVERY alteration to your work and training schedule and then keep hassling your managers, supervisors, medical staffing and payroll to get every bit of extra money you are owed. Your BMA rep should help you with this. If you are an educational supervisor I suggest you lobby the consultant negotiators to increase the time in your job plan for educational supervisor activity or vote with your feet and stop being a supervisor if the work is too onerous or not remunerated enough. If enough people are annoyed and enough money is being lost then government will have to listen. I fully intend to pile up exception reports on the trust,  as the juniors at every hospital I've ever worked at, work above and beyond their "rostered  hours". It's not unprofessional to be paid for what you work and the well of goodwill has run dry.

So considering I wasn't a fan of the JDC I still think there is positive work I can do for juniors locally within the  BMA. I believe in Unions and being a BMA rep isn't just a line on my CV.  I've been on the JD Facebook forum and there is a lot of ill feeling towards the BMA. Good. Once again, people need to vote with their wallets or nothing changes. If they start losing money by cancelled subs then they might realise they can't get away with treating our contract negotiations like a student debating club. There is a lot unharnessed anger on there but words (he says writing a blog), twitter rants, stickers, YouTube raps and candlelit vigils achieve very little.

It leads me to wonder what I would change about the BMA as clearly they have missed the mark nationally with the JD contract negotiations. As far as I was concerned the JDC were doing a great job up until they embarked on a roadshow to get a "yes" vote in June's contract referendum. It was this point they could have just accepted the contract or kept neutral in any referendum campaign. Then on getting a no vote they could have continued with the 2 day strike actions that had worked earlier in the year. The BMA isn't just a union, it's statement about Scottish Whiskey today shows that they try to be public health watchdogs; which is what I thought Public Health England were. I wonder if the make up of the JDC sets us up to fail. We are all unpaid volunteers with medical careers which as far as I know trump our role as BMA reps. It therefore is natural that having such a major national role for JDC can be full of distractions and conflicts. I'm not sure about this but I don't think the JDC chair gets to work on the job full time and take time out of training. Maybe having more legal or union minded non medics or even full time medics seconded to the role full time for a period  may help when developing a negotiating strategy. Lastly, the communication from BMA is patchy and leaky at best. Their email server tends to send mail out in slow batches so people get news in dribs and drabs, when we were getting news at all. I like the step that the new chair as taken to get himself added to the regional chat forums in order to get news and views directly to him.

 It was always going to be difficult job not to get screwed over as eventually I want my certificate of completion of training and already put up with a lot to get it. If there is a silver lining then the May 2016 contract is a sight better than the November 2015 contract and I'm not too ashamed to throw away my BMA badge holder. You never know where I could end up if I fell into this role so accidentally. I hear the catering at BMA house is fantastic; it must be as it comes out of my considerable subs!

September Strike

I originally wrote this post in September but deleted it after I became a local junior doctor BMA rep and realised it isn't exactly complimentary about them. I read the original post again and still agreed with the sentiment so am re-posting. I can still do a job for the BMA locally and not necessarily agree with what they are doing nationally (Stickers against imposition, anyone?)




As my twitter feed and previous posts here show, I wasn't too enamoured with the idea of the government imposing a contract that would result in worse hours and less pay. I went on strike in January and again in April. I waved a placard, canvassed for the BMA and put my point of view across on social and old school media.

Next week I won't be on the picket line.

The first reason is simple, I can't afford to lose £600. The other reasons are slightly more elaborate.

After ACAS negotiations the BMA emerged with what they said was a decent, albeit not perfect offer from the government. Upon reading the revised deal, I could see it was a vastly different contract to the original contract that was due to be imposed which I went on strike over. I attended a BMA road show where I was told that my concerns about a pay cut, unsafe hours, part time workers and reduction in pay progression had been addressed. New hours safeguards and adherence to EWTD were in place. A guardian of safe hours was to be implemented. An online hours breech system was to be introduced to accurately reflect how much we work. The BMA said this was the best they could get and we should accept it. I duly accepted it in the most recent vote. 58% of my colleagues didn't.

My colleagues have that rejected that contract offer can strike and do so with a clear conscience that their demands weren't met, and I support them. My conscience will not allow me to strike over a contract that I was willing to accept. This also leaves me looking somewhat like a government stooge which I'm very much not!

The fact that the contract is still felt to be discriminatory to women, part time workers, academics and career changers (like me) seemed to be lost on the BMA at the time. Why couldn't they use their considerable resources to have the contract reviewed by the country's top legal minds? Why not re-ballot about whether 5 day strike action is the way forward. Conversely, why bother with the "referendum" at all if the contract offer was so good. Why come out so in favour of the contract initially and aid implementation when the response to losing the referendum was to undertake more intense strike action than before?

For me the contract was always about pay, but we seemed to be too scared to say it. It was always about pay but not in the direction some people think. I'll say it again because people don't seem to get it.

I DON'T WANT A PAY CUT, I AM NOT ASKING FOR A PAY RISE,

The thing is pay IS linked to conditions and getting the same pay but working more difficult hours IS linked to patient safety. They are not separate issues. We shouldn't have let the narrative get shifted to "Lazy, greedy doctors want more money!". It think the BMA have been outmanoeuvred by the government and now news outlets are running negative stories and the BMA appear off the pace. They look silly now that they are striking on a contract they took great effort to endorse. Don't blame on malice what can be explained by incompetence.

 The problem with more strikes is the possibility that this is used by the government to preface further erosion of the NHS as a free healthcare system. Rota gaps and service closures are de rigueur and all this can create a picture of a service in chaos.  I posted lots of ways we could have had industrial action that wasn't all out strike, even in my BMA feedback but this is the way it's gone.

The market value of my service is more than I'm currently paid as I work in a monopoly, and a I take that difference because I like working in a service that places patients and not money first. Even though I want to keep the NHS, paradoxically a private system would benefit most doctors financially. Market forces can't apply to me as I only have 1 employer option if I ever want to be a consultant so any strike action was never destined to last more than 2 weeks. Any longer than this and I would not be passing my appraisal for the year.

So what was my solution? We use the systems in the new contract to our advantage. Currently when I work late because I'm helping a patient I don't spend more time filling out overtime sheets or "breach forms" as nothing useful comes from them and I definitely won't get paid any more. New proposals to link e-rostering for our shifts and actually pay us a proportion of current trust overtime charges and would mean filling out these forms could actually make a difference. I jokingly used to count up all my unpaid overtime and call it my "NHS Goodwill Fund", but it stopped being funny after it quickly started mounting up. This is overtime not because I'm lazy or slow, but because patients are sick, theatre lists and clinics are crammed and there are definite rota gaps.

Much like when GPs shocked the government with their excellent adherence to receiving QoF payments I think junior doctors should have strongly adhered to new e-rostering rules and tell hospitals how much they are working and pester their "Guardians of Safe Working" to be paid for all of this extra work they are doing and the BMA would have something to work with. I estimate that the government thinks we don't work as much unpaid overtime as we do and 50,000 doctors showing their time receipts and giving hospitals big bills for this overtime is the way forward.

I think the contract issue is unwinnable as I will definitely still be working for my CCT and will end up sign anything put in front of me to keep my training number and mortgage paid.

So, overall I won't be striking, but I don't condemn my colleagues who will be, and I hope the public doesn't haul too much abuse at them. After all the public won't know how good they had it, until it's gone.

Northamptonshire Green Party Air Quality Crowdfunder

This crowdfunder is to allow us to monitor the air quality in Northampton and hold the council to account on their low emission strategy.

Personal Strike FAQ

Since the new junior doctor contract hit the headlines about 6 months ago, I've been asked my opinion by medical and non medical friends alike. Most  have been supportive, some confused, a few not supportive. I thought I'd direct them to a FAQ so I didn't have to keep repeating myself.

Why do you want to strike?

Like a good politician I will not actually answer the question, I will answer the opposite of the question to appease people who think I'm greedy.                  


 I DO NOT WANT A PAY RISE.

OK, now I've cleared that up, I'll answer the actual question.

 I can see why the BMA wants to keep the narrative about patient safety, inability to cover rotas (seeing as we can't already) and discrimination to women and part timers. However for me when it comes down to it, I do not want a pay cut. As a trainee who has changed career I have benefited from pay progression in my years as a surgeon. With pay progression scrapped for career changes and academic trainees will doubly affect me. My argument for keeping  pay progression is that my experience in surgery has positively affected my work in this post pretty much everyday. The pregnant lady who I knew had appendicitis from her walk across the waiting room probably agrees.

 Seeing as my rota is not changing my previous post explained how I might get a pay cut. As a single income household with 2 kids and a mortgage I really don't fancy losing nearly £5k a year. I actually think a pay cut should be enough of a justification for industrial action but there we go. Entitled doctor opinion or not. Vocation is a wonderful thing which I have in spades, but unfortunately it isn't legal tender.

As I need to break even to pay my mortgage, my solution to the pay cut would be to work more locum shifts. This sort of shoots any "I'm really worried about the amount of hours I work" argument out of the water. However caps to locum pay would  mean almost a 50% cut in take home locum pay. The free market should be allowed to be free, except for public sector workers.

The other thing is that would sort of go against having another agenda for wanting to strike is a hypothetical situation where we were given the current contract and complete loss of hours safeguards but we'd all be paid 80 grand a year. Do you think we would all be out on the streets? I wouldn't be.

As it happens I agree with the wider argument from the BMA that the junior doctor contract is one facet of a wider campaign to undermine the staff in the NHS in an attempt to open it up to private investment. Others including getting rid of bursaries for student nurses and the health & social care act. This happens to be a convenient vehicle to voice concerns in general.


So you agree with the strike action, Why are you scabbing then?

Almost exactly the same answer. MONEY

I'd love to say my intense desire to keep my patients safe compelled me to cross the picket line. That was not really the case as at no point were any inpatients in any danger during any of the strikes.

It is the fact that I would lose £200 a day for each strike day that is what compelled me. When you are borrowing money from your Dad to pay your MOT and spending every other "rest day" in A&E locumming, losing £400 a month is quite a hit.

I was quite happy to work and let my colleagues strike, ones with no kids or money worries. You could say it is short sighted to not strike when you stand to lose out in the long run. That is what the government wants unfortunately, and my bank manager won't accept late payments because of my staunch principles. I can't afford jam today, so I'll worry about today now and worry about later, later.


What would it take to get me to be happy with the contract?

Well, I'm not really sure, which is why I've put my faith in JDC to negotiate for me. Probably a complete reversal and no change would satisfy me, but that isn't going to happen.

The problem with the old contract is that banding payments only have a few levels (50% 40% 20% 5% and nil) and this meant that people working wildly different hours could be paid the same. For example as a surgical registrar I worked a partial shift pattern with overnight on calls. The urology registrar worked every other Saturday and no nights. We were on the same salary. The new contract won't address this issue as the pay cuts will mostly affect those that work the most unsociable hours, making people like myself in Obstetrics worse off and people in day time "office" specialities better off.

So essentially, I'll be happy if the BMA are.

What would a 7 day NHS look like?

I don't know, and that is the problem. There have been no sample rotas, no plans to open clinics or theatres at weekend, no plans from our trust about how we will provide this "Truly 7 day NHS". What is the point of introducing a new contract if we don't change our working patterns. When I'm operating an elective list on Saturdays have the trust got plans to pay for ODPs, porters, scrub nurses, support workers who also need to be there? I don't think so.

Salford has managed to provide excellent 7 day emergency access to MRI etc. and have a Standardised Mortality ratio of 88 (This is good). They have done this with current staffing and contracts.

Didn't we pay for your training?

Yes, you did, and bloody good value for money as well. I'm old and lucky enough to only have £25k of student debt and the taxpayer put up about £175k over 5 years. That's quite an investment. One solution would be a golden handcuff to keep us in an NHS post for 5-10 years post qualification. That will only reduce numbers coming in the door or poor students attending. The thing is where would such a policy end? Teachers? Nurses? Police? Anyone who works in the public sector should pay back all their education fees? What about those working in private sector, they are using taxpayer education to profit someone else, is that right? Does this mean that nobody should get state funded education? Having a well trained workforce is good for the country but there needs to be good enough jobs to keep people there.

Here I will put paid to the myth that your taxes pay for all my post graduate training is not good value for money. Whilst HEE pay some of my salary I can guarantee you that the time I spend in post graduate "training" is actually spent providing a service at a cut price. All the discharge paperwork, cannulas, radiology forms, coding paperwork actually contributes to the running of the service, not just my "training". So beware people who quote £500k as a training figure as that includes my salary for all my years in training. Of course, my post graduate "training" isn't passively looking over a consultants shoulder and absorbing knowledge. A lot of service work goes into it as well. If I do an appendicectomy at 2am on my own, am gobbling up your money being trained? Or am I actually providing a service within the remit of my current skills?


What is your solution?

Unless enforced ill health, misadventure or a better long term alternative comes along, I won't give up my National Training Number. This puts me in somewhat weak position with regards to the new contract. Now I have a family and a mortgage and am not yet a consultant so I can't just up sticks and leave for Oz like last time. So whatever happens I'll be at work in August. I can't say the same for my colleagues. In my department alone we have 1 going to Scotland, 1 moving abroad and 1 leaving medicine all together. I know the plural of anecdote isn't evidence but I did a teaching session for our 14 FY2 doctors last week. More of them were moving away, locumming or taking time out than staying for a specialty post. Maybe a zero hour, poorly trained cohort of juniors is what the government want?

Next BMA action could be to not sign any one up to a new post in August and instead form a locum agency to outsource trusts own doctors back to them at locum rates. Then nobody has to strike and it will show you how much a medical workforce could cost. Indefinite emergency only care is an option but suffers the same problems that caused me to scab this time. We could work with the deaneries to give all trainees 3 months "out of program experience" so nobody had to lose their training numbers and nobody starts work on August 5th. This is difficult to achieve seeing as HEE is a government agency.

The NHS is a monopoly employer so I can't just go and work and train at the hospital down the road.

Do you want to bring down the government?

Well, Yes. I'm a member of a political party which isn't the conservative party, so seeing the government brought down would be great. Just not over the JD contract dispute. There are lots of reasons not to like what is going on in the current government, but it's not out of character is it? People knew what they were voting for and they're getting it.

New junior doctor contract is a pay cut: A proof

Many people have eloquently expounded the problems with the contract from a patient safety point of view.  The government have said I won't get a pay cut, and some of my non medical friends have asked me what my problem is as I'm getting a 13.5% pay rise. So I thought I would compare my current pay with the proposed pay from the new contract. Hopefully I can prove I am getting a pay cut despite the government assertion that I'm getting  a 13.5% pay rise. #algebra

I have a 1:8 rota where I work 7 nights (8pm-8.30am) every 8 weeks and 1 Saturday and 1 Sunday day shift every 8 weeks (8am-8.30pm). I also work 5 long weekdays every 8 weeks(8am-8.30pm). Every other day is a normal working day or rest day. As far as I know our department is not planning to change the rota despite the need for 7 day services. I therefore will be working the same hours in August as I am on now. Our rota is EWTD compliant, i.e. we work no more than 48 hours per week on average. Just for the record, I've worked a very similar 1:7, 1:8 or 1:9 rota in every hospital job I have had in the UK, so I don't work a particularly unusual or busy rota, I'm not in the small minority.

Prove by contradiction that new contract will result in a pay.

I will use the assumption that I will not get a pay cut.

Current pay = Proposed pay

Current pay is a 50% banded job  = 1.5x (x = basic salary for 40h/wk normal working days)

Proposed pay: (source NHSE)
 Nights attract 50% uplift
 Sundays attract 30% uplift

 87.5 of my 384 (48hrs per week x 8weeks) hours over an 8 week period are nights. ~23% which attract 50% uplift

and 12.5 of my 384 hours over an 8 week period are long day Sundays. ~3% which attract 30% uplift

No uplift is attracted for weekday long days or Saturday long days. This means 74% of my hours attract normal rate.

New basic salary = y = 1.135x (13.5% payrise)

Proposed Pay breakdown: 0.74y + [0.23 (1.5y)] + [0.03(1.3y)]

multiplying out gives us:

0.74y + 0.34y + 0.039y = 1.119y

substituting y = 1.135x

New pay = 1.27x

1.27x =/= 1.5x

QED

I'm OK for 3 years as my  pay protection is worth the ~4.8k a year I will lose. This is an appreciable amount of money. This is stated very clearly on my NHSE pay calculator. This won't help the new doctors starting  this year or doctors coming from abroad who will be worse off than I am, despite doing the same job.

Not fair is it?

Hunt's Long Game

Last weekend there was a twitter tag #iminworkjeremy which got big enough to be picked up by the mainstream media. My Twitter feed being a small left wing microcosm (after the general election Labour twitterers were so confused "but all my followers voted  Labour and we still lost!"), I didn't think it would go very far but the independent and the BBC picked up on it. My tweet was included in the buzzfeed article but not the independent one. Probably because it was such a terrible selfie! My vanity aside, the whole thing was a response to criticism of hospital doctors by the Health Secretary Jeremy Hunt.  Now his plans for 7 day working have been rebutted in depth by much cleverer people than me here and here. Funny that, doctors might be smart and well researched and be able to analyse a flimsy paper on which you hang the weight the entirety of the 7 day NHS reforms.

Now the first question is "Do we need 7 day a week care?". The answer is clearly yes, you can't have parts of the service close at weekends as it is inconvenient and potentially risky, as some of the government analysis shows. Most of the doctors on the #iminworkJeremy were engaged in emergency work which continues 24/7 as my 3am laparotomy patient can attest. However the solution to provide more services isn't to make doctors work harder.

I worked as on call registrar for general surgery last Saturday and for some of the day the senior decision maker for patients potentially needing surgery. One of my patients I decided  needed an ultrasound scan. This couldn't happen until Monday. The next patient needed an endoscopy. This couldn't happen until Monday. The next patient needed to see a stoma specialist. This couldn't happen until Monday.

This is in no way a dig at my colleagues in radiology, endoscopy or stoma care. Quite the opposite. They work as hard as the rest of us. Medicine is a team sport and it can't work if only one cog in the wheel is made to spin harder. I'm useless as the surgeon if there isn't a whole array of specialists and technicians to support patient care.  All the other services including scans, scopes, bloods, portering, wound care, community which are not funded to work at weekends, need to be, with enough recruitment and funding to cover this. You can't expect a 40% increase in productivity with and 8% increase in funds. But that won't happen, as it would be expensive.

The next, more interesting question is "Do we need 7 day a week Elective care?" A more difficult answer. In my opinion, No, we don't. Firstly, is there any evidence that performing routine care at evenings and weekends improves patient safety? I can't find any. Does it improve access and patient satisfaction. To an extent yes. But would spreading services to weekend without extra money force us to lose service provision in the weekdays thus making patient safety worse off? In my experience the only clinics I used to do which were underbooked were evening and Saturday clinics. This is because people want to use  their leisure time not in the doctors surgery. I don't think it would be a good use of resources risk patients in the week by making us work more at weekends. What is proposed is a massive increase in provision of service without the same level of investment.

Which leads me onto what I think would happen.

Many people have commented on how naive or inept Hunt is. I do not believe this for a second. I think he is a very clever man with a very clear aim. He wants to privatise the NHS and open it up to becoming a more US style system. Not only due to his donors and previous publications on the subject see Direct Democracy 2005, but the tactics being employed stink of a plan to privatise a service.

Firstly, defund. Check. There is potentially a £20bn shortfall in NHS funding despite the challenge to find the same in efficiency savings. An £8bn pre election promise and £500m winter pressure payments are sticking plasters. To say we spend a lot on our health service is interesting when we spend as a proportion of GDP less than most other developed nations.

Secondly, demoralise. Check. First the GPs by trying to get them to make more sausage with less meat, by getting them to open 8-8 7//7 with no proportional funding increase. Criticising them through CQC, print media and press releases. Making promises of extra GPs which anyone who could see GP  application numbers falling could see was nonsense. Funny how this was shelved immediately and quietly after the election. Next by telling consultants and hospital staff that they are not working hard enough or long enough. This is patently untrue. Myself and my consultant bosses are as dedicated and present as ever as shown with the huge outpouring for #iminworkJeremy. My 12 years of training, numerous hours in the NHS goodwill fund after my shift finished as well significant personal and financial sacrifice has enabled me to provide decent care for my patients, to be told I don't have a sense of "vocation" would be laughable if it didn't anger me so much.

Lastly, and this is the best part of the plan. Get the doctors to destroy the NHS. Privatising the NHS openly in the UK is political suicide. It will be for the forseeable future. It is one of the few things this country has to be proud of. Therefore in order to execute the plan, the only group powerful enough to resist changes need to be the ones to destroy it.

Here is how it might go. Try to enforce an inferior contract on doctors. Either the BMA roll over like they did for the pension reforms or Industrial action ensues as the only option for an oppressed workforce; despite the weakness of the BMA there must be a line somewhere. (If the RMT were in charge of us, we'd have downed tools already!). Media blame money hungry doctors as the cause of strikes and worsening conditions in NHS hospital. Mass resignations  by doctors and serious patient safety incidents in understaffed hospitals would leave the government no choice but to introduce a pay it yourself service and blame the doctors for not willing to work for free or have more sense of "vocation". And there he has it. A nice juicy service ripe for the picking so he can go and advise the  board at private healthcare plc and make a tidy pension.

What am I doing about it other than moaning on social media. I've joined the BMA for what it's worth as well as a non government political party, to at least get my views out there. I don't want money to play a part in whether patients get care, no-one should profit from ill health directly and I think the ideals of NHS is what keeps me in the UK at all. Of all the country's family silver it should be the shiniest, well looked after piece and not for sale, covert or otherwise.

The Long Road Home

6 month between posts, you could be forgiven for thinking this blog had gone on permanent hiatus. Just been bust moving house, starting yet another new job and trying to look after our newly minted  2nd child.

I started this blog in 2009 to chart the time of being an  FY1 doctor straight out of medical school. Initially I chronicled my worries and flip flopping about what specialty I wanted to do for the 40 odd years. It regularly changed but by the time my foundation training had finished in 2011 I had narrowed it down to either Surgery or Obstetrics & Gynaecology. Usually, you enter specialty training straight after completion of foundation training.

Next week, 4 years later, I finally start Obstetrics & Gynaecology training.

Firstly, I am very happy to be finally on course in a training program which ends in CCT and my next interview is potentially for a consultant post. Especially in a specialty I have long wanted to join.

So why did I take so long?

2 reasons really.

Firstly, I wanted to gain experience in both before embarking on one or the other. Other than a 1 week taster course I did not do any O&G as an FY doctor so went abroad to work in O&G in Australia for a year. This firmed up my decision to proceed with O&G as I loved  both the medical and surgical aspects of a job as well as the intense emotions on the labour ward. This accounts for a 1 year delay and leads onto the next reason for it taking so long.

I'm terrible at interviews. Absolutely so. I have had many and had lots of practice and courses to improve the problem. My CV wasn't bad and neither were my clinical skills yet my communication skills, which when measured in work based assessments as good crumbled to terrible in a job interview. I don't know why, perhaps I've always had a problem with getting nervous around people in authority.

I had 3 interviews in 2012, 1 for O&G, 2 for Surgery which was more a second choice to ensure I moved back to the UK.

*aside* I know one should never embark on a career like surgery as an alternate choice, but at the time moving back to UK was more important. *end aside*

I failed 2 of them on communication skills and passed a surgery interview but not well enough to get a post outright and was placed on the reserve list. 10,000 miles away I anxiously waited for other candidates to reject the job I wanted. I got it and moved back to the UK.

I still wanted to pursue O&G so in 2013 applied again. Failed again, worst than the first time. Made many of the same mistakes and despite knowing them seemed unable to resolve them. As I had the job in surgery I resolved to go wholeheartedly into general surgery. I could be and proceeded be the best core trainee I could. I did all the courses and log books and exams and assessments and publications and teaching and management degrees and interview prep and in 2014 applied for a higher surgical training job. The same thing happened. Completely froze in the interview and despite getting the clinical skills and portfolio right failed on the communication skills. I get into knots as I try and 2nd guess the interviewer and then hesitate to find the correct words.  This led to me having to get a staff grade middle grade surgery job somewhere at short notice. Which is why I spent 2014-15 in the furthest reaches of Yorkshire.

Which is where I had to make another decision. 3 years in surgery and I had learnt to do a lot but still had the confidence issues and still not able to secure higher training jobs. Do I continue a 3rd time at surgery or cut losses and do something else entirely. I had failed O&G twice, did I want to go through it again now I was 3 years from my last experience in it? I wasn't enjoying the lifestyle away from family and friends and with 2 kids to look after we needed some roots. I love operating and working with families on the labour ward so tried again to get an O&G post back home, which is what I had wanted all along. Was it difficult to give up 3 years after starting surgery. Yes it was. A part of me will always run the "what if" scenarios in my head. Perhaps I would have got the training job with more experience, but I doubt it as I was away from an academic centre as a non training doctor. Maybe I would have had a rewarding career as a surgeon. I get the feeling I made the right choice. Many colleagues told me "You're far too nice  to be a surgeon." Which may well be the case, but it also meant I wasn't ruthless  or hardheaded enough to get on,so perhaps it was for the best.

  Now I write this from my  house in the East Midlands about to start run through training with my lovely larger family! I think the year as a registrar gave me the confidence to finally pass a communication skills exam. 4 years late via Queensland, West Yorkshire and about 100 appendicectomies, but I'm where I want to be finally! Are there still worries? Sure thing. I have got used to some of the benefits of being a registrar and will have to go back to being a novice and probably a lot of admin and mundane work. I'm worried I'll blur the line between my old role and new role. I'm worried people may expect too much from me, having been a surgical trainee in the past.

Is there a lesson to be learnt from this?

Perhaps, stop dithering and make your mind up earlier? I don't know, I think it is possible to love 2 specialities and researching will only get you so far. I think if you are equally happy in either, then persuing either is fine.

Prepare more intensely for interviews and work on flaws harder? Perhaps, but how much can you iron out an inherent flaw in your technique, stumbling over  words. Sheer bloodymindedness worked eventually as I passed the interview on the 3rd attempt.

Be flexible and open minded about your options? Medicine is an incredible career and its variability is what makes it so interesting.

So I think finally if there is anyone struggling to figure out what they want to do in medicine, it is OK to go a circuitous route if you can justify your decisions and it makes you interesting. You don't have to flow smoothly from one MTAS designed program to another. I honestly feel my 3 years in general surgery are going to come in mighty useful in the next few years. You'll get there in the end. Or not, and you can do something else equally interesting and fulfilling.

Phrases that annoy me: Part 3

"It's only a silly game."

With my 2 favourite sports being football and cricket, today was a big deal for me, with England getting knocked out of the Cricket world cup by Bangladesh and United hosting Arsenal in the FA Cup quarter final. I did have a brief Australian based foray into rugby league but that is for another time. Also the United game hasn't started at the time of writing so I thought I better write whilst I was at least half optimistic the day won't turn out terrible.

Anyway, I expressed my disappointment at being knocked out of the world cup on social media along with many other folk who follow England, as well as mentioning it at work. I was quickly confronted by the phrase:

"Why do you care, it's only a silly game?"

Now the issue with this isn't that I'm annoyed people don't like cricket. They are allowed not to like it. I belong to a fairly small group of people in my social group who does enjoy the game, In fact, if you can understand the game you probably find it boring; it's impenetrability & "oldman-ishness" is part of it's charm.

What I don't like is people taking something I like and reducing it to being "silly". It's only silly  because you don't like it. There are 90,000 people at the MCG on Boxing Day who don't think it is silly. What people mean when they say it's "silly" is actually "I don't understand or like this activity, but it appears to provoke some sort of emotion in you, how odd".

Everyone has different interests and pastimes that make them happy, frustrated or out of pocket. That is what makes being a human so good. There really are thousands of things to wile away your precious time.

The thing is, every activity that is not related to acquiring food, sex or shelter is inherently pointless, it's up to us as humans to find stuff we enjoy. Yes cricket is essentially pointless but then so is everything else.

 Therefore, I enquired into what the particular interests were of the person who uttered the phrase.

Formula 1, wine drinking and Amateur Dramatics. Now, I don't go in for any of these activities and I could write an essay on what I don't like about Formula 1, but I don't think any of those activities are "silly" even though all of them are pointless.

So, let me enjoy my pointless activity and I'll let you enjoy yours.

Phrases that annoy me: Part 2

"You're not doing nothing, Doctor."

From time to time, I have to deal with unhappy patients or staff members. This is part and parcel of the job, and it is why we undertake many hours of communication skills training to deal with these situations effectively. Shouting, swearing and name calling I can deal but the title phrase irks me every time I hear it, and whenever I do, I always try to confront it.

Obvious double negative notwithstanding, this is the only phrase I hear at work that really makes me cringe because it is so obviously fallacious. I understand long waits and being in pain do not mix well and I can understand people's frustration but the initial consultation is not usually where I hear this phrase and if I do I tend to apologise for their wait and implement some resolution to this.

I usually hear this phrase from people with whom have had repeated interactions with healthcare professionals with repeated investigations, treatments and consultations. Now I understand people remaining in pain which hasn't been diagnosed and treated can be frustrating but telling me I haven't done anything to help hurts, as that's what I am there for.

This may not have been the best way to handle such a complaint but I challenged the assertion of the last person who told me "You're not doing nothing, Doctor."

In an effort to show the person that we were taking them seriously I presented all of their pathology, radiology, endoscopy, microbiology and histology results as well as every consultation in the notes with a HCP and every dose of pain relief, anti emetic and vital sign observation. I normally take a much more conciliatory tone but it is something in the phrase that is accusatory about our teams perceived collective laziness which is just untrue. Fortunately, this approach worked as we came to a better understanding of the others position and managed to work out where we could go next.

I sense most of these type of complaints aren't malicious and usually can be dealt with at the bedside as they stem from frustration and fear rather than a true attempt to declare our service inadequate. Most offers to speak to our complaint department are rebuffed. However sometimes, and this is only my observation, but many of the people who use the phrase are younger and have an expectation that whatever is causing their pain can be diagnosed  and sorted out immediately. The reality of the situation is sometimes at odds with a patients expectation of instant relief.

Sometimes an adequate explanation of what is going to happen at the start of the consultation can help prevent this sort of problem. For example when a patient presents with abdominal pain and the diagnosis of appendicitis is equivocal it is accepted practice to enact a period of "watchful waiting" where we measure vital signs and blood tests over 24 hours to see if there is any resolution/deterioration. This is because some things that mimic appendicitis can disappear on their own and appendicitis usually deteriorates. It helps identify patients who would not benefit from an invasive procedure (appendicectomy).

However if patients do not know that this is our plan, then they can understandably become upset when in 24 hours they only have 4 or 5 BP readings to show for their stay. This is our responsibility to ensure patients are fully involved in our decision making process.

So there are two ways I see that I can hear a reduction in the use of these phrases. Firstly, adequate communication and expectation setting by the HCP treating the patients and secondly some patient education on what they can expect from their health care system.

Phrases that annoy me

"You need to broaden your horizons."

It's nice to be able to expand on something in more detail than 140 characters, having recently finished my complete transplant onto twitter.

Somehow, over the last few years I have gained a reputation for being a bit of a home bird and not being very adventurous with travel, food or pastimes.

Over discussion today about a fish restaurant that was the venue for a work night out, I was asked what I thought. I stated I don't like fish so probably wouldn't want to eat there unless there were other things on the menu. I was quite happy to go along and eat chips and bread-sticks so I didn't derail anyone else's night. Then one of my colleagues uttered the title phrase.

"You need to broaden your horizons."

Now, I may have narrow interests and horizons but that it because I have had broad horizons and chose to narrow them, because the broad ones were rubbish and gave me dysentery. When it comes down to it, I like simple things like football, fast food and pubs.

It is one thing to be resistant to change, it is entirely another to have experienced different cultures and decide that you don't actually like it. This is something many of my friends don't understand. How can you have visited the 4 corners of the globe but want to go for dinner in the same pub in Northampton? It is very simple, I compare gastronomic experience to my yard stick (Bacon cheeseburger) and if it is not as nice I don't go for it again. I don't see why you can just do the things you enjoy, many people I know seem to do odd things just because they can. I understand, I was like that a few years ago.

I've been to every continent except Antarctica and sampled many a dish and activity. Some, like bungee jumping and guinea pig I never want to repeat again. Others, like test match cricket and tacitos I have taken to my heart and carried them on. When on my elective in South America, the group of travellers I was staying with also noticed how I was less than thrilled with some of the "experiences" on offer. One jokingly said I should write a travel guide titled "The world through the eyes of a grumpy bastard."

The example they were referring to was the description of my trip to Machu Pichu:

"A World Heritage site? It took 5 days to walk there and all I was greeted with was pepsi stands and panting tourists. Magical ruins? More like boring rocks, the church in my village is older and prettier. At least climbing up Wayna Picchu meant I could look at the site and leave the panting tourists to their angina."

I think it has some legs, but Karl Pilkington appears to have cornered the market in the genre since I went so it'll probably not make me my fortune. I have diaries of all the major holidays I have been on and some of them make me chuckle but I'm not grumpy, honestly, I just like very simple things!

So, the phrase annoys me because it assumes that I haven't experienced life enough. I have, I just choose to be boring.

Obelisk of Light

One of the few things I do which doesn't involve work and makes me happy is playing football. Now I'm no professional but I played for a Sunday league team for 5 years in various positions . I was more upset about leaving the team behind when I moved than most other things about leaving Northampton. The thing I liked most about it, was the fact that it was a Sunday league football team that wasn't completely populated with angry, hungover meatheads. We were probably the politest team I've ever seen. This was both good and bad for results!

So the first chance to go back and see how they are doing I took last week. In the time I have played for them they went from 2nd division also-rans to being in the top Sunday league. They mostly achieved this without my help as we recruited young talented students to replace the old timers like me. So it was sad to see them bottom of the league and in trouble of going under.

A number of reasons behind their fall from grace. Firstly the students who carried us to glory have  all graduated and left the team. Secondly, it is very difficult to run a Sunday league team with any sort of sustainability. You need to recruit, organise games, pay officials, buy & wash kit, organise training, liaise with league officials. You also need to chase up players for money to fund all of this.

Now once this was done by one group of people and over time it was taken over by another group of people. I think the amount of work involved became too much and they have fallen by the wayside.

It is very sad and I wish I had enough time to take over and sort it all out.

I'll add it to the  list of things I can't do due to work!

4 hours in A&E

Much is made of the 4 hour waiting target for A&E departments in the UK and various hospitals' adherence to the target as well as methods hospitals use to fudge the  numbers to make it look like they adhere to the target.

The Mary Seacole Program which I have just completed exists as a direct  result of the Francis Report trying to improve education and leadership in the NHS workforce. Something mentioned in the Francis Report was the fact that Mid Staffs were placing adherence to targets  above the need for safe patient care.

I understand that fast care should result in improved patient safety and satisfaction and targeting time spent in the A&E department should bring about improvements. Unfortunately imposing arbitrary and artificial restraints on a system will mean that the system will adapt to nullify the effect of the restraint. This took the form in mid Staffs of holding wards, inappropriate discharges, boarding patients in inappropriate places and generally harassing staff who were there to see the patients. In my experience I've seen all of these in one form or another in the various places I have worked. I would like to share an example of the unwavering adherence to the 4 hour rule and how ludicrous it can make us look.

It was a Saturday night and I was on call for Urology. I was called to a very busy and rowdy A&E department to see a patient with a painful urological problem which whilst distressing was quite easy to fix and would result in complete resolution and discharge from hospital immediately after the procedure. It was uncharacteristically quiet in theatre so I proceeded to A&E without delay to be met at the entrance with a clip board wielding band 8 nurse who was "site manager" for this shift. This is hospital speak for "enforcer of 4 hour wait rule"and the extent of her first interaction with me that evening boiled down to:

"Majors 12 has been here 3 hours 55, Send him home now or he is going upstairs [to the admissions unit]"

Firstly, I was referred the patient at 3 hours 50 minutes and expected to sort them out in 10 minutes. Secondly, having reviewed the patient quickly I was confident the short procedure would send him on his way home. This would probably take about 5-10 minutes to perform, but would take him over 4 hours in the department. This obviously couldn't do.

After confirming the problem, I left the room to get a pair of gloves and the piece of equipment needed to help the patient out, having applied some local anaesthetic to the area in question and leaving the patient in a compromising position in the private room. In the 10 seconds I took to get the gloves, a porter and "site manager" had gone into the room and wheeled him out (still in a compromising position) in order to transfer him to the admissions ward.

My protests fell on deaf ears:

Me: "I'm only going to take 5 minutes, he doesn't need to go upstairs"
Manager: "He is about to breach, whatever you are doing it can wait until the admissions ward."

So it takes half an hour for patient to be transferred and admission paperwork to be completed before the patient is in a room able to do the procedure. I have a very irate, embarrassed patient who has been paraded in front a department with his pants down. It takes less than 5 minutes to do the  original procedure yet he has been admitted, had an admission nurse fill out a booklet full of paperwork and been subjected to a humiliating trip. All so he didn't breach the 4 hour target.

What should have happened is that he would have remained in the department for 4 hours and 5 minutes and he would have gone home happy. This chain of events hindered the nurse on admissions, myself, the porter and most importantly the patient. It didn't help anybody and wasted a lot of time, effort and money. Thankfully other than a complaint, it didn't actually harm the patient. I'm sure there are many other examples that have.

So that's why I don't like the 4 hour target; it makes people do silly things in order to get the numbers correct.

Trauma Services in Westeros

A perpetual state of war is the perfect environment for innovation in healthcare to flourish and nowhere is this more in need than Westeros. Currently trauma services are in disarray with pauper and king alike at risk from mismanagement in the dangerous world of the 7 kingdoms.

Alarm bells began with the peacetime death of Robert Baratheon in a hunting accident. Adequate access to quality surgical and anaesthetic care may have prevented the realm being plunged into chaos in the first place. Given his stability at presentation he had time for a full history and examination including co-morbid conditions of obesity and alcohol dependence. Expedient wound debridement and surgical control of intra-abdominal sepsis with post operative ICU care and prevention of alcohol withdrawal would have probably prevented the War of 5 Kings.

With war on 3 fronts, expert medical care was largely an afterthought with  only the Northern Army having any noticeable care for wounded soldiers. Not that this could save their king in the North from succumbing to a cross bow bolt trauma which could have been decompressed with an intercostal drain and appropriate blood products. Things got worse at the Battle of Blackwater with no recognised Burns unit in the capital leading to thousands of unnecessary deaths barely hundreds of feet from the gates to the city.

The next king to suffer from poor investment in his own healthcare system was Joffrey, appearing to die from poison setting off severe laryngeal oedema. Being in the biggest population centre in the realm would mean prompt management of a threatened airway with access to intubation and in extremis a surgical airway. None of which was forthcoming, which leads to cries of regicide.

Things are little better across the Narrow Sea in Essos where leader of the Dothraki, Khal Drogo has succumbed to wounds inflicted in a minor scuffle. Here, appropriate access to antibiotics and sepsis source control will have negated the need to use poorly defined and non evidenced based therapies used by the Blood Magi. Being Barbarians, they could be forgiven for not having a well developed trauma service, but this must become a priority given how much blood is spilt in their name. They need only look towards slavers bay for an effective surgical practice. Becoming unsullied requires an invasive procedure and the fact there are 8000 survivors is testament to go post operative care and cleanliness.

There are reasons to be optimistic, not least in the survival of the  Kingslayer after a grossly contaminated forearm amputation was promptly managed with haemorrhage and infection control from Masester Qyburn, who whilst spurned by the Maesters in their Ivory towers is producing some promising results in acute care situations, results of his treatment of the Mountain are awaited with some excitement.

So what is the answer? The Maesters and the Master of Coin need to sit down and plan an effective and wide ranging trauma network throughout the 7 kingdoms. This should start with a dedicated level 1 major trauma centre in the capital to serve the population of in excess of half a million people. This should be equipped with access to immediate radiology, general, orthopaedic, vascular and cardiothoracic surgery as well as the opening of the Oberyn Martell Memorial neurosurgery unit. This should be complemented by a hub and spoke system of trauma centres located in the major population centres of the largely rurally populated Westeros. Transportation to the MTC should be provided when patients are stable in view of the  large distances involved. Furthermore, field care should be provided by mobile trauma units following the great hosts of Westeros to war and at Tournament, with a banner befitting their neutral and altruistic nature. Lastly the Maesters need to be up to date with evidence and all must attend an ATLS course as a matter of urgency to learn how to care immediately for the injured in battle or intrigue.

Now is the perfect oppurtunity to improve trauma care in Westeros and only short sighted temporary leaders will prevent this.