Trust me.......I'm a doctor!

For the past several months in England there has been a long-running and increasingly bitter dispute between the government and doctors concerning a new contract that the government wish to bring into force. The doctors through their professional association – the BMA (British Medical Association) have fought the new provisions on two fronts; firstly that they will lose out financially if the contract is brought into being and secondly that if it is established its effect will be, as they see it, to threaten patient care and provision. The government for its part argue that the contract is necessary if we are to have a better, more efficient health service. Negotiations have gone on for months, the government arguing that they have made a number of amendments to their original offer in order that the doctor’s concerns are met whilst the doctors argue that should the contract come into being in its present form many will leave the profession or go abroad to work.

Where right and wrong lies in this dispute clearly depends upon which side of the political divide one sits but what cannot be disputed is that positions have become entrenched and neither side seems likely to move. The government, in the shape of Jeremy Hunt the Health Secretary, has announced that discussions are at an end and he will simply impose the contract.  Doctors, for their part, have become increasingly vociferous and embittered. Earlier this week the Guardian published a letter from a doctor who also happens to be the daughter of an ex-Conservative minister and colleague of Jeremy Hunt, Andrew Mitchell. Dr Mitchell was scathing in her criticism of the government and of Jeremy Hunt in particular:

I read with deep regret the news that Jeremy Hunt has decided to impose the new junior doctors contract. What Jeremy Hunt has managed to achieve is nothing short of spectacular. Health secretaries have come and gone, imposing new measures of varying unpopularity on the NHS but not one has managed to so completely unite doctors in their dislike and alienate healthcare workers across the board in the way he has. He says we lack vocation, he paints us as the problem. The morale of the workforce is at breaking point. With imposition, the goodwill of doctors who work hours beyond those they are rota-ed and paid to do will dry up.

The health secretary is not even clear on what he means by a seven-day-week NHS. He continues to misuse research to support his arguments. He has been told the statistics he uses are not correct, meaning he is either dishonest or stupid. I don’t know which is worse. He demonises the BMA, and lies about their actions. They are not a militant union; they are the very moderate voice representing junior doctors in the UK.

I am one of the many junior doctors who have left the UK. If he goes ahead with imposition of contract, I am certainly unlikely to return to the UK to continue clinical practice. The health secretary has alienated an entire generation of junior doctors. We have no confidence in him. He must be sacked.

Dr Hannah Mitchell
Gaborone, Botswana

The National Health Service in the UK has an almost mythical standing – it is a brave or very foolish politician who seeks to manipulate or change it. No one would argue that it is perfect but it has become such a treasured and integral part of British life that whichever party is in power must, if they are to retain public support, ensure that the NHS is safeguarded. In short it is a “sacred cow”.  The issues implicit in the current dispute go to the very core of the service: how can the staff and resources be managed and improved to ensure better provision, how can  the massive funding be better managed and thirdly, what is the most effective use of an already overstretched staff. And, crucially, there is the undeniable fact that no matter how well the NHS does or how much money is invested, it can never really meet the expectations of the populace; we always want more!

I certainly have no answers. I have absolutely no doubts that the wonderful service devised by Nye Bevan in the aftermath of the Second World War is, to a degree, no longer fit for purpose. We are living in a different age – we cannot simply keep pouring more and more money in to preserve things as they were. For example, when the service was introduced all prescriptions were largely free – this to ensure, at a time of great poverty, that ordinary folk could access basic medication and help; times in those days were hard, far harder than they are today. Each month when I stand in my local chemist to pick up my month’s supply of cardiac medications I am embarrassed; although prescriptions are not now free they are still free to older people like myself or at a heavily subsidised cost to everyone else. I stand there and in my heart of hearts know that I should be making some contribution to the huge cost of what is given to me each month. Similarly, an appointment to see my GP is free. On Thursday I visited my local hospital for a spinal injection to ease my slipped disc problems. Last year I had this done in a private hospital – cost about £500. The cost of this latest (and exactly the same) procedure done at my local NHS hospital  was nil ..... and I also got a cup of tea, a cheese sandwich and a packet of biscuits thrown in! Of course, many would argue that I as have paid my taxes all my life so am entitled to this. Well, maybe so – but I am not poor and could afford to make a contribution in order that others less fortunate than me might enjoy the same facilities for nothing. That seems to me to be some kind of moral imperative but, for sure, it is at least an important and basic bit of humanity.

Would I buy a used car from this man? Do I think that he
is totally honest? Do I think that he can be trusted.
No on all counts. Jeremy Hunt is a political whizz kid -
his only allegiance is to Jeremy Hunt.

When Bevan and his colleagues set up our welfare state and NHS in the late 1940s there were certain clear principles – available to all, no matter their circumstances and free at the point of delivery being two. But there were other, perhaps less clear principles or assumptions which are often forgotten. The welfare state was never intended to keep people in some kind of luxury and the NHS was intended to alleviate people from the fear and pain of illness. I suspect that if Bevan or Attlee were to return today they might hold their hands up in surprise at what they saw; people like me of reasonable wealth accessing hugely expensive medications and services for free or people accessing NHS resources for conditions such as cosmetic surgery that may be desirable but certainly not life threatening/changing situations where medical intervention is absolutely necessary. They would find what we spend money on via the health and welfare budgets not what they anticipated or intended all those years ago when they introduced the system to save people from the very real ravages of widespread health issues and poverty. We live in different times and it is right and proper that we look very carefully at how the service can be made relevant to the age in which we now live and reflect our changed circumstances be they financial or social.

The costs of health and social provision in the modern age is eye wateringly expensive. Although we might blithely say that as a rich nation we can afford it, the reality is that it is inappropriate to keep pumping more and more money into services that can never, in the modern day and age, satisfy everyone’s wants and desires. As medical advances find new technologies and procedures to offer or as society’s needs become greater in terms of expectation any government has to address the question of what is ‘reasonable’ given the situation. Increased funding, new ways of working, the use of the private sector, various forms of ‘rationing’ of resources or rationalisation of working practices might all come into the equation somewhere. Our aging population and pro rata a smaller workforce paying taxes to fund provision increasingly puts greater strains upon welfare and health resources and budgets – that fact alone is sufficient to require any government to responsibly review how it funds and manages provision. Not to do so would simply be an abdication of their responsibilities.

This might seem that I am taking the government’s line here – well maybe so, but not quite. There are I think wider issues which maybe lie at the heart of the present dispute. My suspicions and beliefs on this matter seemed to me to be confirmed by a statement by Jeremy Hunt a couple of days ago. Talking of the bitter dispute and the sort of condemnation and vilification that he has received from doctors Hunt was unapologetic saying that: “I was talking to Ken Clarke [a previous health secretary] yesterday and he was saying how he was pursued by nurses to the airport when he was going on holiday with his family – the BMA put up posters of him all over the country. I had a similar conversation with Norman Fowler and someone was telling me yesterday how Patricia Hewitt had the mums of junior doctors pursuing her everywhere she went,” . Hunt added that there had been “one or two incidents, [of him being pursued by angry doctors] but it goes with the territory.”

For me that is a telling indictment and confirms the comments made by Dr Mitchell in her letter – that there is clearly a lack of basic trust between those working in the health service and the politicians in charge. For me there is something uncomfortable when a government minister  can treat so  dismissively the very real concerns and, perhaps,  anger of highly thought of professionals. I would suggest that it is a matter of profound regret and concern that successive health secretaries appear unable to build up a relationship of trust with those charged with perhaps the most important part of a government’s responsibility – the health and welfare of its citizens. This breaking of trust has just been brought into even sharper focus; a young doctor has been missing for several days in Devon  and as police search for her suicide is high on the list of likely outcomes. The doctor concerned apparently left a note where she named Jeremy Hunt’s decisions and actions as possibly a factor in her anxieties. If this proves to be the case then clearly politicians like Hunt cannot simply accept and dismiss the ire of those they represent and are responsible for as just a sort of "bad day at the office" issue.

Trust is the issue here – an understanding, recognition and trust of the values, beliefs, motives and expertise of the very professionals charged with the delivering of the welfare and health of the nation. It seems to me that traditionally (and maybe it's even more true today as the media, politicians or pressure groups seek to influence opinions as never before) doctors have been one of the small group of professionals in society who people expect to “tell the truth” and be untainted by other factors. We call upon the services of doctors when we as individuals or society as a whole are faced with profound problems - our health or the health of our loved ones and the health and welfare of wider society. And when we call upon their services then we expect an entirely truthful and unbiased action; indeed doctors take an oath to this effect upon qualifying. The same might be said of judges (but not necessarily lawyers since they might be representing another interest) – we expect our judges to act and comment entirely truthfully and their views be regarded as totally honourable and beyond criticism. If this is not the case then the very basis of our laws and justice are in danger. Another group that carries this mantle would, of course, be those involved in the church – the vicar, the cardinal, the rabbi or the imam.  We might not agree with their particular faith but we would respect their views and advice because somehow we accept that they will be truthful.  As an ex-teacher I might say that teachers once fell into this category – but sadly not any longer as successive governments have taken away their professional standing and brought the morals of the marketplace into a school administration and the classroom. As I write this I am reminded of my son who is an accountant; he often jokingly says “Trust me, I’m an  accountant”............and he then adds with a smile “I can make any number mean what you want it to mean!”.Quite – accountants, like bank managers, once fell into this truthfulness category but in the past decade and especially  since the debacle of the financial crash they are now regarded as distinctly untruthful by many. Of course, I’m sure that my son like most accountants and bank managers are every bit as truthful as every priest or doctor or judge – but as a profession they have largely lost that perceived characteristic and moral high ground

I am not suggesting that every doctor, priest or judge is a paragon of virtue - far from it.  But as a society we have to believe  and trust that these people will act in our best interests. If we cannot trust them then who can we trust?  By the very nature of their professions, they operate at the very heart of what it is to be human and a member of a society - they deal with matters of life and death and of ultimate right and wrong - and if they cannot be trusted then I have no doubts that society is not only at a very low ebb but is in danger – for it is these people throughout history who have frequently stood up for basic values and rights. They are the people to whom we instinctively turn to for advice, support or assistance when times are at their darkest. When people face great sorrow or loss it is often the priest to whom we turn for solace  or advice; when we feel wronged we turn to the judge through our justice system; when we are at death’s door it is into the doctor’s hands that we place ourselves........and in each and many other cases we have to expect and perhaps subconsciously know, that, at the end of the day, these people will act honestly and truthfully and in our best interests. They are trustworthy.

Politicians like Jeremy Hunt, however, are today amongst the most despised and mistrusted groups in society. This of course is unfounded; I’m sure that many politicians are honourable trustworthy people – but that is not how they are perceived and certainly not what their record shows. And quite frankly, if I listen to the arguments about the problems in the health service, whilst I might recognise the problems faced by Jeremy Hunt and others as they strive to manage this expensive but benevolent leviathan it is the doctors (and nurses etc) views that I will relate to and believe rather than the politicians. Partly, I will believe them because they are actually working, they have a stake in the service so know its problems and opportunities first hand. But mostly I will believe them because not to do so questions the very basis upon which our society and democracy ultimately rests. Sadly, like many others, I cannot say the same of politicians -  I will always suspect that they are being economical with the truth and/or pursuing a hidden agenda. This is  a worrying indictment on our modern society.

There are many, like myself who believe that Hunt’s (and the government’s) plans have a more sinister and cynical basis than  simply making a few economies in the NHS. A report out today by the independent think tank The King’s Fund suggests that “the NHS [is] nearing “make or break” , with “widespread pessimism” within the service.”  Patients are getting “poorer care from the NHS in England as its funding crisis deepens, with trusts forecasting a £2.3bn deficit by the time the financial year ends....... [there has been] a return to central control of budgets from Westminster with funding decisions increasingly tied to tough cost reduction targets. More than half the trust finance directors believe care provided in their area is deteriorating, the first time such a figure has been reached since the surveys began in 2011”. Well, one might say that merely proves Hunt’s point: something has to be done. But I would retort, we’ve been here before with, for example, our rail network  and indeed our schools or prison service. It is, as Noam Chomsky famously argued “classic capitalist strategy”......defund the service  so that increased problems occur; people get angry and complain; the government blames the problems the inefficient system and sell the business to  private capital at knock down prices and say everything will improve”. Things, of course, don’t necessarily improve but the government has profited by a few billion pounds, got rid of its responsibility and can no longer be blamed for any problems that arise. I can very easily see that this is Hunt’s and the government’s real agenda – blame the doctors and others for the system's increasing problems until the point is reached whereby privatisation appears the only option.

The public’s cynicism and lack of trust in our elected representatives inherent in the above scenario has to be frightening. We are on a slippery slope downwards   Maybe I’m just old-fashioned – but quite simply I would not like to live in a society where I thought the priests or the judges or the doctors were not ultimately truthful – it brings to mind recollections of dystopian societies of the most extreme kind:  Nazi Germany, Stalin’s Russia or Mao’s China and it questions the very foundations of democracy. It is George Orwell's 1984 made real. 

They can see the writing on the wall! Chomsky's prophecy
is being made real in  our NHS - "defund, demoralise
and then sell off." Watch what happens in the next few years.

And a final point. Small and pedantic in itself but perhaps a small measure of how out of touch Jeremy Hunt is. It was brought to my attention in the Guardian letter page a few days ago. As the dispute between the doctors and government reached crisis point Jeremy Hunt announced that further discussion was useless and that he was going to “impose the doctors'  contract”. As a Guardian reader pointed out, the legal and the literal definition of a contract is that it is an agreement, voluntarily and freely entered into between two or more parties. The very nature of a contract is such that it cannot be imposed if one party does not agree to it or has not freely entered into it. If it is "imposed" as Hunt suggests then by definition it ceases to be a contract. The whole notion of a contract has implications of truth and mutual respect – that both parties will act in good faith, recognise the rights and expectations of the other and honour the agreement that they have made.  It is exactly the same as a wedding contract where the happy couple freely and voluntarily make certain promises to each other. Neither party can be coerced into agreeing the contract. No one would argue that a wedding “contract” can be arbitrarily imposed on one partner by the other – but Mr Hunt and his colleagues seem to believe that this is their prerogative so far as the doctors are concerned. Whether by ineptitude,  crass stupidity or blatant dishonesty Jeremy Hunt has broken the basic trust that must underpin our basic human negotiations and  relationships. As Dr Mitchell commented “....he is either dishonest or stupid. I don’t know which is worse”. For me he is, like many of his colleagues, a thoroughly untrustworthy and unpleasant man ...........and the frightening thing is, that he sits in government over us.