The NHS and the Reality of the New Junior Doctors' Contract.
I am a junior doctor who works in the Accident and Emergency department of a Midlands’ hospital.
It’s a hard job, like many within the hospital. The pressures on the staff and the department itself are considerable.
Over the past months, with the evolving dispute surrounding the contract for junior doctors, I, like my colleagues, have watched with intrigue. Intrigue has made way for indignation, disappointment and anger.
We have tried to remain professional despite the thinly-veiled attacks on our integrity and sense of vocation, our outrage cemented in false statistics and sensationalist reporting designed purely to denigrate the NHS and every single person who works within it.
The furore has dimmed somewhat since the announcement of imposition of the new contract, in the media at least. This has at least given us all time to reflect on what has happened.
I have read as many articles and posts from as many different sources as I have been able to. Many are in support of the juniors and the NHS as a whole whilst some have demonised the BMA. Others have tried to simplify this action to a pay dispute.
I’d like to try to describe my last week to you and explain why this is a dispute about something else entirely.
It is about providing the opportunities for patients to have their lives cared for, adequately and professionally, so that they can leave the hospital in a better situation than when they arrived.
This is about fuller and happier lives for the families of those patients who can build new memories, enriched by the presence of a loved one.
And it is about life for the people providing that same care.
We need the environment and the system in which to optimise the delivery of the care we are capable of giving in order to save lives, improve them and empower them. It’s what we strive for every day.
We also need the environment to balance our own working lives against our need for social interaction, rest, learning, adequate nutrition and maintenance of our physical and emotional health.
Without this, it is not possible to offer the best care that any of us can hope to provide.
And that is a travesty for patients.
From last Saturday (20th Feb) in seven days, I was Rota’d on for 72 hours. This comprised of:
Fri 19th: off
Sat: 14-0200
Sun: 14-0200
Mon: 12-21
Tues 12-21
Wed: 2200-0800
Thurs: 2200-0800
Fri: 2200-0800.
In reality, I worked nearly 85 hours.
On Sunday evening I left work at 0340, got home at 415, went to bed at 0500 and was up at 0930 before another 10 hour shift that turned into twelve hours.
I had one proper break all week- that is, half an hour to sit and eat a sandwich and have a cup of tea. I had one proper meal.
I missed my scheduled teaching for the week because I was on nights. I had a meeting on Thursday morning after my night shift to discuss why I had missed so much teaching and the extra e-learning I would need to do in order to compensate for this, as well as that already required that I was yet to complete.
I crashed my car on the way home.
That night I led the care of a seven week old in cardiac arrest due to an undiagnosed narrowing of their aorta and a hole between the atria in their heart. We were successful.
The other patients I remember from the week were a gentleman who I told required further investigation because he had a brain tumour; a lady on chemotherapy who had an overwhelming infection; a 10 year old with a life-threatening asthma exacerbation; and a lady who had been hit with a hammer in the eye.
We were so busy one evening we had someone with a supraventricular tachycardia, another with a bowel obstruction and another with a diabetic ketoacidosis in the waiting room- we just had no space to put them into a room.
These people were critically unwell and there is an energy that comes with that. This is what we are trained for. This is what we do.
The patients that turn out to be more difficult when you are tired are those inbetween; blood results unremarkable, imaging without abnormality, but distinguished clinical signs.
Send home or admit? GP follow up or medical review? Non-specific abdominal pain or appendicitis?
When you are tired, the mistakes lie here. In the grey areas. And it is so easy to miss.
For example: A man comes in with a respiratory tract infection. You treat it. He is epileptic. You refer him, and he is to be transferred to a medical bed. You are not informed there is a delay in transferring him to the ward. He doesn’t receive his regular medication because you didn’t prescribe it in your rush to see the next patient. The nurse tells you and they prevent a fit. You feel awful; but until you see his face you can’t even remember him because you’ve seen 10 patients since and numerous relatives.
1g of paracetamol prescribed; but the patient is 45kg and you didn’t check. She should have had half that. My colleagues prevent me overdosing her.
I enter the department each day and look at the bed board and hope I don’t recognise any names of patients that I treated the day before.
We finish late on shifts because we can’t leave these patients. We aren’t clock-watching.
It is not straightforward to hand over the details of a case to a colleague and ask them to contact intensive care. It is better for the patient that we do it ourselves; so that is what we do.
Sometimes, there is nobody to hand over to. So we stay on. Because that is what we do. That is what is right.
We don’t take breaks so we can tell your relatives your blood tests results and the likely course of a new diagnosis or life event. That is normal.
We do this in an increasingly litigious society where our mistakes are magnified and we are punished, rightly, for our errors. Twice this week my consultations have been recorded by relatives, once without my knowledge at the time.
Is it right I am being pushed more and more by my seniors, by my health secretary, by my government?
Is it right that I am in increasingly difficult environments that make it more likely that a patient will come to harm? More likely that I will end up in court with the coroner? More likely that my career will stall? More likely that my health will be affected?
I go on holiday in my fixed annual leave and realise it is the first time I have had to process the cries of the woman I comforted after we lost her 5 month old daughter on Boxing Day. A week after she had lost her husband in a motorbike accident.
I remember the 11 year old who tried to resuscitate her 42 year old mother. We couldn’t save her. She wouldn’t let me go when I told her and I watched her grow up in front of my eyes as she comforted her father when he arrived and was so stricken with grief he couldn’t get up from the floor for an hour.
I need to be alert, well-rested and healthy. For these patients and these relatives, they deserve for me to be at my best.
And I need to be at my best for me too.
I do this job so families and friends can share more precious moments together. My chosen career doesn’t afford me the same opportunity.
If the new contract is, as planned, imposed in August, this week will be more normal for my colleagues.
Being at my best will be impossible.
And despite not agreeing that the care I provided last week deserved the £6.54 per hour (£5.40 if calculated under the terms of the new contract) I received, that is not what our profession is concerned with.
For patients and all healthcare staff, this contract is morally, ethically and fundamentally wrong.
