Junior doctors: asking the right question

A government source (anonymous of course) has told the BBC that junior doctors, in their long running dispute, are really trying to topple the government. It appears some in this government really think that this dispute is their version of the 1984 miners’ strike. A compromise to trial the new contract, which would have almost certainly led to the strike being called off, was rejected by Jeremy Hunt as ‘political opportunism’.

It is natural when this kind of standoff happens to choose sides. The government is trying to introduce a 7 day week culture into the NHS: are they trying to do this ‘on the cheap’ by suppressing pay (and safeguards against excessive hours), or are the doctors being unreasonable and putting lives at risk?

I think that is the wrong question. A much better question is to ask how this dispute came about in the first place. The mine workers had a long history of strike action, but this strike by doctors is unprecedented. Unlike coal miners, doctors are not in a declining industry, and they are not led by the likes of Arthur Scargill. Instead they are a key part of a sector where demand continues to rise, and technology (for the moment at least) tends to add rather than reduce costs.

In this context, this government and its predecessor have tried to do something pretty radical, which is to reduce the share of NHS spending in GDP (for a chart from the Kings Fund, see here, and for details of the NHS squeeze see here). It is part of their attempts to reduce public spending, initially under the pretext of deficit reduction but in reality to allow tax cuts. In their typically Orwellian way, they call this ‘protecting the NHS’. Their hope is that this squeeze on resources will reveal and end inefficiencies which until now vested interests, lethargy and bad management have maintained.

An alternative way of achieving the same goal is to embark on a top down reorganisation that you believe will make the system more efficient.

The 2010 coalition government tried to do both at the same time. You do not need to be an expert on the health service to guess that trying both at once would be a disaster. Any kind of successful wholesale reorganisation of a large organisation costs resources in the short term, even if it brings benefits in the longer term. Predictably, according to the experts, this reorganisation was “distracting and damaging”.

Did the new (2015) government learn the lesson? Silly question. Introducing a 7 day week culture into the NHS may well be a good idea in principle, although the evidence is not nearly as clear as Hunt suggests (which is why trials are a good idea). Using dodgy statistics to suggest to the public that going into hospital at weekends rather than a weekday was dangerous was an extremely irresponsible thing to do. To the extent that there is a problem it is unclear whether doctors are critical to it. But even if the reform itself is justified, it is another reorganisation that requires resources in the short term.

Aneurin Bevan, who set up the NHS, said that to persuade reluctant doctors to accept the idea he had “stuffed their mouths with gold”. Reorganising doctors’ contracts was bound to create winners and losers, and in a profession with considerable solidarity that would not be agreed to without extra money to compensate the losers. To try and do it while starving the system of resources was just crazy, and allows doctors to tell themselves that they are striking to save the NHS rather than to protect their pay.

The only similarity with the miners strike is that the doctors also cannot force the government’s hand. The more they escalate the dispute, the more their solidarity and public support will fragment. Jeremy Hunt has already got away with putting party interest above public probity once in a previous job, with Cameron’s active assistance, and he may profit this time as well. If he does demoralised UK doctors will leave in increasing numbers for more congenial working conditions overseas, and gaps will be filled by doctors trained overseas (if the home secretary lets them in).

The question to ask is not which side is right, or whether the strike is justified. The critical question is how did we get to this situation, and what that tells you about this government’s competence. The NHS works on relatively meagre resources because of the goodwill of those that work within it. Do we really think that facing down UK doctors is the way to get a better NHS? If the government does not compromise, the only losers in this dispute will be you and me.

Postscript (29/4/16) This by Ben Dean in the Telegraph makes similar points, and even questions whether the new contracts are better than the old in achieving a true 7 day week goal.